losartan-potassium and Blood-Loss--Surgical

Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythrocyte Transfusion; Erythropoietin; Humans; Iron; Perioperative Care; Postoperative Complications

Anemia can contribute negatively to a patient's morbidity and mortality. Which treatment options do exist and what role do anesthesiologists play in management of perioperative anemia treatment? This review gives an overview about recent findings.. Patient Blood Management and standards for the management and treatment of anemia have been established worldwide. Various logistic settings and approaches are possible. With a special focus on cardiovascular anesthesia, intravenous iron is a therapeutic option in the preoperative setting. Autologous blood salvage is a standard procedure during surgery. Restrictive transfusion triggers in adult cardiac surgery have been shown to be beneficial in the majority of studies. Elderly patients and defined comorbidities might require higher transfusion triggers. Both, intravenous and oral iron increase hemoglobin values when given prior to surgery. Oral iron is effective when given several weeks prior to elective surgery. Erythropoietin is a treatment decision individualized to each patient.. Within the previous 18 months, important publications have demonstrated the established role of anesthesiologists in managing perioperative anemia. A substantial pillar for anemia treatment is the implementation of Patient Blood Management worldwide.

Topics: Administration, Intravenous; Administration, Oral; Age Factors; Anemia; Anesthesiologists; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Erythropoietin; Humans; Iron; Operative Blood Salvage; Perioperative Care; Professional Role

Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions.. The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events.. A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47-0.73; P < .001) as well as patients undergoing cardiac (n = 9 studies; risk ratio, 0.55; 95% CI, 0.37-0.81; P = .003) and elective orthopedic (n = 5 studies; risk ratio, 0.36; 95% CI, 0.28-0.46; P < .001) surgery compared to placebo, respectively. Preoperative erythropoietin was also associated with fewer phase-specific red blood cell transfusions. There was no difference between groups in incidence of thromboembolic events (n = 28 studies; risk ratio, 1.02; 95% CI, 0.78-1.33; P = .68).. Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Topics: Blood Loss, Surgical; Blood Transfusion; Erythrocyte Transfusion; Erythropoietin; Hematinics; Hematopoietic Stem Cell Transplantation; Hemoglobins; Hospitalization; Humans; Inpatients; Preoperative Period; Risk; Sensitivity and Specificity; Thromboembolism; Transplantation, Homologous; Treatment Outcome

Pediatric craniosynostosis surgery is associated with significant blood loss often requiring allogenic blood transfusion (ABT). This study explores the clinical effectiveness of preoperative erythropoietin (EPO) administration in pediatric craniosynostosis surgery in reducing transfusion requirements.. A systematic review and meta-analysis of the literature was performed for studies published in English language between 1946 and 2015. Inclusion criteria included original studies in the pediatric population (0-8 years of age) involving preoperative use of EPO in craniofacial procedures with quantitative reporting of perioperative blood transfusion. Extracted data included demographics, hematocrit, hemoglobin, estimated blood loss, number of patients transfused, and amount of ABT.. Four studies met the inclusion criteria with a total of 117 patients. Patients were divided into 2 groups: EPO versus control. No statistical differences were found in the demographics between the 2 groups. Mean preoperative hematocrit level was higher in the EPO group compared with control (43% vs 35%). The percentage of patients who required ABT and the volume of transfused blood were less in the EPO group (54% vs 98% and 84 vs 283 mL, respectively). Meta-analysis of 3 comparable studies showed a lower proportion of patients who needed blood transfusion in the EPO group.. The present meta-analysis demonstrated that preoperative administration of EPO in pediatric craniosynostosis surgery decreased the proportion of patients requiring ABT. In addition, the volume of transfusion was reduced in patients who received EPO. Future randomized studies are needed to establish the cost-effectiveness of routine preoperative EPO administration in craniosynostosis surgery.

Topics: Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Craniosynostoses; Erythropoietin; Hematocrit; Hemoglobins; Humans; Infant; Infant, Newborn; Preoperative Care; Treatment Outcome

To assess the use of oral iron, intravenous (IV) iron, and erythropoiesis-stimulating agents (ESAs) for the prevention and management of perioperative anemia in elective orthopedic surgery patients, and to provide a clinical algorithm for use.. A PubMed and MEDLINE search was conducted from 1964 through March 2016 using the following search terms alone or in combination: orthopedic, surgery, elective, anemia, blood transfusion, iron, erythropoiesis-stimulating agents, and erythropoietin.. All English-language prospective and retrospective human studies and meta-analyses evaluating oral iron, IV iron, or ESA alone or in combination in elective orthopedic surgery patients were evaluated, provided they reported blood transfusion outcomes.. A total of 9 prospective and retrospective studies and 1 meta-analysis were identified and included. In the preoperative setting, administration of oral iron, IV iron, or ESA alone or in combination to correct underlying anemia led to significantly reduced transfusion rates. Transfusion requirements were generally less with combination therapy (ESA + oral or IV iron). In the short-term perioperative or postoperative period, use of oral or IV iron led to conflicting results, with some reporting a statistically significant reduction in blood transfusions, whereas others reported none.. In elective orthopedic surgery, IV or oral iron with or without an ESA may provide benefit in prevention of postoperative anemia and results in blood transfusion reduction without significantly increasing the risk of adverse events. These agents should be considered at the lowest effective dose with emphasis on administration prior to planned surgery.

Topics: Administration, Intravenous; Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoietin; Female; Hematinics; Humans; Iron; Orthopedic Procedures; Prospective Studies; Retrospective Studies

Erythropoiesis-stimulating agents (ESAs) are widely used in treating anemia associated with renal failure. They are also now used perioperatively to reduce the use of allogeneic blood transfusions (ABTs) in patients undergoing surgery with anticipated high blood loss. Although they can reduce the risks associated with ABT and improve quality of life, the use of ESAs is still associated with adverse effects.. A narrative review is provided on ESAs and a systematic review has been conducted to examine the current evidence for the efficacy and safety of perioperative ESAs use. A search of PubMed and Medline databases has been performed using a combination of search terms including erythropoietin, perioperative, surgical, safety and efficacy.. Current evidence supports the use of perioperative ESAs to reduce the need for ABT. However, large studies assessing safety in anemic patients with chronic renal disease have found adverse effects including cardiovascular, stroke and thromboembolic events. However, whether these concerns can be conferred onto the surgical population remains to be seen as the perioperative dosing strategies have been more variable in timing, dose and duration in comparison with those used for chronic diseases. Future research needs to address the questions of optimal dosing strategies in order to maximize the positive effects and minimize adverse events.

Topics: Anemia; Animals; Blood Loss, Surgical; Blood Transfusion; Drug Administration Schedule; Erythropoiesis; Erythropoietin; Hematinics; Humans; Perioperative Care; Postoperative Hemorrhage; Recombinant Proteins; Risk Factors; Time Factors; Treatment Outcome

Total hip arthroplasty is associated with marked blood loss, with the potential for up to 90% of patients requiring allogeneic transfusions. Also, perioperative-induced anemia is associated with lower postoperative functional scores, increased mortality, increased cardiovascular risks, longer hospital stays, and postoperative infections. The purpose of this review was to analyze the recent evidence on preoperative blood management strategies utilized for total hip arthroplasty. Specifically, we evaluated the use of preoperative iron therapy, intravenous erythropoietin, and autologous blood donation. No single strategy was shown to be superior over another in reducing the need for allogeneic transfusions; however, a combination of these blood management strategies may result in improved blood loss outcomes. Larger prospective randomized studies comparing the individual strategies, as well as combination therapies, are needed to develop a concise statement on the most effective and efficient preoperative blood management treatment algorithms for total hip arthroplasty.

Topics: Anemia; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion, Autologous; Causality; Combined Modality Therapy; Erythropoietin; Evidence-Based Medicine; Humans; Injections, Intravenous; Iron; Preoperative Care; Prevalence; Risk Factors; Treatment Outcome

Elective total knee arthroplasty is frequently associated with considerable blood loss and a concomitant decline in hemoglobin postoperatively. This often leads to high rates of allogeneic transfusions, with reports of up to 69%, to treat postoperative anemia. Allogeneic blood transfusions have been shown to be an independent risk factor for increased adverse outcomes, such as prolonged length of hospital stay and postoperative infections. Although multiple preoperative blood management strategies have been proposed, there are no concise guidelines, as few studies have compared the relative efficacy of these techniques. The aim of this review was to evaluate current evidence on the various preoperative blood management strategies for patients undergoing total knee arthroplasty and to provide an overview of the safety and efficacy of these practices. Specifically, we evaluated preoperative autologous blood donation, iron therapy, and intravenous erythropoietin. Current evidence suggests that these techniques independently may be effective at reducing the incidence of allogeneic blood transfusions, correcting preoperative, and preventing postoperative anemia. However, more studies are necessary to evaluate combination protocols, as well as the cost-effectiveness and safety of these practices as part of routine preoperative blood management for total knee arthroplasty.

Topics: Algorithms; Anemia; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Humans; Injections, Intravenous; Iron; Postoperative Complications; Preoperative Care; Trace Elements

Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.

Topics: Anemia; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Blood Transfusion, Autologous; Blood Volume; Case Management; Drug Therapy; Erythropoiesis; Erythropoietin; Hematinics; Hemodilution; Hemostatics; Humans; Iron; Operative Blood Salvage; Patient-Centered Care

High energy trauma is often responsible for acute bleeding. Long bone and pelvis fractures are correlated with increased blood loss. Hypovolaemia could become a life threatening complication especially in elderly patients because of the reduced physiological response. Furthermore it could compromise the course of associated morbidities. Haemorrage is also associated in both comminuted fractures and osteoporosis. An increased intraoperative bleeding often occurs when a prolonged surgical time is required to obtain an appropriate ostheosynthesis. The final consequence of a mayor bleeding is hypovolaemic shock. The reduced oxygen tension of the tissue may be responsible for heart attack, arrhythmia, stroke, multi organ deficiency. For these reasons, it is important to immediately recognize and correct all potential bleeding in order to avoid complications.

Topics: Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Hematinics; Humans; Orthopedics; Shock; Wounds and Injuries

Bloodless surgery programs are being instituted because of increasing public concerns about blood transfusions and the need to accommodate some patients' religious beliefs. Patients' desires to forego transfusion must be identified during the preoperative screening process and subsequently reflected on the surgical consent. Patients are managed preoperatively with erythropoietin and dietary supplements. The surgical team employs a variety of intraoperative and postoperative blood conservation techniques to help avoid the need for transfusion. A retrospective review of congenital cardiac procedures in a blood conservation program confirmed that bloodless cardiac surgery is effective.

Topics: Blood Loss, Surgical; Blood Transfusion; Child, Preschool; Christianity; Epoetin Alfa; Erythropoietin; Heart Diseases; Hematinics; Humans; Infant; Perioperative Nursing; Recombinant Proteins; Retrospective Studies

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].

Topics: Anemia; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Drug Administration Schedule; Erythropoietin; Ferric Compounds; Ferric Oxide, Saccharated; Ferritins; Glucaric Acid; Hematinics; Hemodilution; Humans; Intraoperative Complications; Orthopedic Procedures; Postoperative Hemorrhage; Preoperative Care; Recombinant Proteins; Sucrose; Time Factors; Tranexamic Acid; Transfusion Reaction

We provide an overview of the principles of blood management: the appropriate use of blood and blood components, with a goal of minimizing their use.. To review the strategies that exploit combinations of surgical and medical techniques, technologic devices, and pharmaceuticals, along with an interdisciplinary team approach that combines specialists who are expert at minimizing allogeneic blood transfusion.. A search on Medline and PubMed for the terms English and humans used in articles published within the last 20 years.. Blood management is most successful when multidisciplinary, proactive programs are in place so that these strategies can be individualized to specific patients.

Topics: Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Erythropoietin; Hemostatics; Humans; Intraoperative Care; Postoperative Hemorrhage; Preoperative Care

Major transfusion-free orthopaedic surgery can be performed successfully. This requires advanced planning, good routines and close collaborative team efforts. Since most blood saving techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative and postoperative blood saving approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, intraoperative autotransfusion, individualized assessment of anemia tolerance, meticulous surgical techniques and the use of pharmacologic agents for limiting blood loss. For various reasons, we do not recommend the transfusion of wound drainage. This article describes the various methods for bloodless medical care.

Topics: Adult; Anemia; Blood Coagulation Tests; Blood Loss, Surgical; Blood Transfusion, Autologous; Child; Clinical Trials as Topic; Contraindications; Cost-Benefit Analysis; Drainage; Erythropoiesis; Erythropoietin; Hematocrit; Hemodilution; Hemoglobinometry; Humans; Intraoperative Care; Jehovah's Witnesses; Meta-Analysis as Topic; Orthopedic Procedures; Preoperative Care; Risk Factors; Time Factors; Wounds and Injuries

The practice of blood conservation is aimed at improving patient outcomes by avoiding allogeneic transfusions via a coordinated multidisciplinary, multipronged approach. The numerous blood conservation techniques and transfusion alternatives now available are described.. Ongoing concerns exist regarding the availability of the nation's and the world's blood supply. In addition, the number of measures required to ensure blood safety has led to increases in the price of blood and blood products over the past 10-15 years. Moreover, blood transfusion carries inherent risks even under the most favorable circumstances. Investigations have established that injudicious transfusion is associated with development of ventilator-associated pneumonia, nosocomial infection, and organ dysfunction. Because most single blood-conservation techniques reduce blood usage by a mere 1-2 units, a series of integrated conservation approaches are required. These include preoperative autologous donation, use of erythropoietic agents, blood conservation techniques such as acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. Erythropoietic agents such as epoetin alfa have been used successfully to increase hemoglobin and decrease transfusion requirements, and are appropriate when used in advance of elective surgical procedures. Acquisition costs of erythropoietic stimulating agents versus costs of blood justify economic evaluation by hospitals to make the most cost-effective choice under current economic constraints.. Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.

Topics: Anemia; Blood Banks; Blood Donors; Blood Loss, Surgical; Blood Transfusion, Autologous; Darbepoetin alfa; Epoetin Alfa; Erythropoietin; Hematinics; Hemodilution; Hospital Costs; Humans; Insurance, Health, Reimbursement; Medicare; Recombinant Proteins

Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units (ICUs) receive at least one allogeneic red blood cell (RBC) unit and average close to 5 U of RBCs during their ICU admission. RBC transfusion is not risk-free, and there is little evidence that "routine" transfusion of stored allogeneic RBCs is beneficial to critically ill patients. It is clear that most critically ill patients can tolerate hemoglobin levels as low as 7 g/dL, and therefore, a more conservative approach to RBC transfusion is warranted. Anemia of critical illness is a distinct clinical entity characterized by blunted erythropoietin (EPO) production and abnormalities in iron metabolism identical to what is commonly referred to as anemia of chronic disease. As such, the bone marrow in many of these patients responds to the administration of exogenous EPO, in spite of their underlying critical illness. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically ill patients, rHuEPO therapy will also stimulate erythropoiesis. In randomized placebo-controlled trials, therapy with rHuEPO resulted in a significant reduction in allogeneic RBC transfusions. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the ICU and decrease the transfusion threshold in the management of all critically ill patients.

Topics: Anemia; Blood Loss, Surgical; Chronic Disease; Critical Illness; Elective Surgical Procedures; Erythrocyte Transfusion; Erythropoietin; Humans; Iron; Recombinant Proteins

Allogeneic red blood cell (RBC) transfusions are associated with multiple disadvantages, such as limited availability, high costs, multiple risks and side effects. In addition, large outcome studies comparing liberal (hemoglobin transfusion trigger range 9-10 g/dL) and restrictive (hemoglobin transfusion trigger range 7-9 g/dL) transfusion regimens still need to be performed for surgical patients. Different transfusion alternatives are known for the pre-, intra- and postoperative period. Autologous blood donation and erythropoietin are efficacious in the preoperative period. Intraoperatively, acute normovolemic hemodilution (ANH), cell salvage, antifibrinolytics, specific anesthetic and surgical techniques, coagulation monitoring, acceptance of minimal hemoglobin values and hopefully soon artificial oxygen carriers can reduce allogeneic RBC transfusions. In the postoperative period cell salvage, antifibrinolytics, and accepting minimal hemoglobin values represent alternatives to RBC transfusions. When treating a bleeding patient, the initial administration of crystalloids and colloids to restore and maintain normovolemia is important. RBC transfusions are recommended under the following circumstances: for hemoglobin levels <6 g/dL and for physiologic signs of inadequate oxygenation such as hemodynamic instability, oxygen extraction rate >50% and myocardial ischemia, detectable by new ST-segment depressions >0.1 mV, new ST-segment elevations >0.2 mV or new wall motion abnormalities by transesophageal echocardiography. The aim of this article is to review the efficacy, risk and side effects of RBC transfusions, to discuss transfusion alternatives and to summarize current indications for RBC transfusions. This information will help the physician to judiciously use RBC transfusions when they are indeed indicated.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anemia; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Cardiovascular Diseases; Child; Critical Care; Erythropoietin; Hemoglobins; Hemorheology; Humans; Immune System; Infant, Newborn; Oxygen; Oxyhemoglobins; Postoperative Period; Risk; Sepsis; Transfusion Reaction

The general concept of blood saving covers a number of technical and pharmacological actions which all aim to maintain the erythrocyte mass of the patient, and of which blood transfusion is only one. Severe anemia (Hb <60-80 g/l) increases postoperative mortality and morbidity. However, its correction by blood transfusion tends to worsen the prognosis. It is therefore imperative to conserve the patient's blood by any means possible. Detecting anemia is of primary importance. Whenever possible, its cause should be identified and treated. Depending on the detected anemia, as well as the blood loss expected during surgery, the patient should receive EPO (anemia with foreseeable moderate blood loss), or autologous pre-donation associated with EPO (anemia with foreseeable large blood loss).

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hematocrit; Hemoglobins; Humans; Perioperative Care

Blood loss during orthopaedic procedures can be extensive and the need for allogeneic blood is a common requirement. However, blood transfusion conceals a number of well-recognised risks and complications and blood products have become more expensive because of their specific preparation procedure. Surgical technique, awareness of the problem and restriction of transfusion triggers are important factors affecting the management of blood loss. Several studies have additionally shown the efficacy of epoetin injections in increasing the pre-operative haemoglobin level. On the other hand, the true benefit of pre-operative autologous donation, acute normovolemic haemodilution and COX-2 selective NSAIDs remains under dispute. Regarding the role of platelet rich plasmapheresis, fibrin sealing and anti-fibinolytic drugs more data are needed. Hypotensive epidural anaesthesia seems to be an advantageous method in minimising peri-operative blood loss. However, this is not a widely performed technique in orthopaedic surgery. In addition, post-operative blood cell saving systems after total knee or hip arthroplasty have been reported to significantly minimise allogeneic blood transfusions when compared to control groups. It can be concluded that many interventions diminish more or less allogeneic blood transfusion in elective orthopaedic surgery. Nevertheless more prospective studies are needed and appropriate algorithms should be applied in peri-operative blood loss management. This review presents an overview of the available interventions which aim to diminish the use of allogeneic blood in elective orthopaedic surgery.

Topics: Anesthesia, Epidural; Anti-Inflammatory Agents, Non-Steroidal; Blood Loss, Surgical; Blood Transfusion, Autologous; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Hemodilution; Humans; Orthopedic Procedures; Recombinant Proteins; Transplantation, Homologous

This review focuses on perioperative blood conservation techniques and the role of transfusion triggers and algorithms, preoperative autologous donation, acute normovolemic hemodilution, intraoperative blood salvage, deliberate hypotension, and preoperative recombinant human erythropoietin in avoiding allogeneic blood transfusion in pediatric patients.

Topics: Anesthesia; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Child; Erythropoietin; Hemodilution; Humans; Recombinant Proteins

One of the primary goals in the perioperative care of orthopaedic patients undergoing surgery is the avoidance of allogeneic transfusion. There are a number of ways to lessen blood loss during surgical intervention including regional hypotensive anesthesia, careful and atraumatic surgical technique, and coagulation of bleeding surfaces. Achieving coagulation is difficult in spinal and arthroplasty procedures because of the large cancellous surfaces that are vascular and are not amenable to ligature or thermal coagulation. All measures of autologous blood salvage should be used including preoperative deposit of autologous blood, hemodilution techniques, intraoperative salvage (when appropriate), and postoperative retrieval and reinfusion. The use of perioperative recombinant erythropoietin is also a useful adjunct to promote stimulation of the bone marrow and increased red cell production. Although many infectious diseases that are transmitted through allogeneic blood transfusions have been lessened by better screening techniques, there is still potential life threatening reactions and viral transmissions that may be avoided by comprehensive blood management in joint arthroplasty.

Topics: Arthroplasty, Replacement; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hemostasis, Surgical; Humans; Perioperative Care; Postoperative Hemorrhage; Practice Guidelines as Topic; Recombinant Proteins; Venous Thrombosis

Pharmacological approaches to reduce blood transfusion include the protease inhibitor aprotinin, lysine-analogue antifibrinolytics synthetic arginine-vasopressin derivatives (DDAVP) and recombinant factor VII (rfVIIa). These agents are known to prevent the need for blood after major surgery (cardiac, hepatic, and orthopaedic). Among the nonhemostatic agents erythropoietin (EPO) may be effective to reduce blood requirements in medical and surgical patients. Aprotinin is consistently effective in reducing blood transfusion in cardiac and hepatic surgical procedures, but there is little data to support its use in elective orthopaedic surgery. Antifibrinolytics show no evidence of efficacy in cardiac and hepatic surgery and its use is not warranted in orthopaedic surgery. Limited data suggest that DDAVP may be effective when a defect in platelet function is demonstrated. rFVIIa emerges as a promising haemostatic agent with proven benefit to reduce bleeding in haemophiliacs with inhibitors but might also be effective in patients with thrombocytopenia and thrombopathy, as well as in life-threatening hemorrhage in postsurgical patients. Ongoing studies will established its role a possible "universal haemostatic agent". Hematopoietic cytokines, such as EPO, may have a place to avoid blood transfusion in a variety of clinical conditions, including cancer and critically ill patients.

Topics: Antifibrinolytic Agents; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Deamino Arginine Vasopressin; Erythropoietin; Factor VIIa; Hematologic Diseases; Hemorrhage; Hemostatics; Humans

The anemia of critical illness is a distinct clinical entity with characteristics similar to that of chronic disease anemia. Several solutions to the processes of anemia, such as blunted erythropoietin production and erythropoietin response and abnormalities in iron metabolism have been developed. The transfusion of RBCs provides immediate correction of low hemoglobin levels, which may be of value in patients with life-threatening anemia. Avoidance of RBC and blood component transfusion, however, is becoming increasingly important as data of adverse clinical outcomes in critically ill patients become clearer. Although the optimal hemoglobin in critically ill patients is not determined, this organ system has a generous reserve. Short-term compensated anemia is tolerated well, while exogenous erythropoietin allows patients to achieve higher hemoglobin concentrations without exposure to transfused blood/blood components. A recent randomized trial enrolled over 1300 critically ill patients to receive either 40,000 units of exogenous erythropoietin or placebo. These authors found that patients randomized to erythropoietin received significantly less allogeneic RBC transfusions and had significantly greater increases in hemoglobin. Although no differences were found between groups in gross clinical outcomes (ie, death, renal failure, myocardial infarction), this study did not have the power to identify small differences in outcomes. This and other studies of exogenous erythropoietin therapy in critically ill patients clearly demonstrate that the bone marrow in many of these patients will respond to the administration of erythropoietin despite their illness, suggesting a blunted production of erythropoietin rather than a blunted response to erythropoietin. Exogenous erythropoietin therefore represents a therapeutic option for treating anemia in critical illness. Acute events in medicine and surgery often lead to many patients becoming anemic. Solutions to this process of anemia should be focused on preventing such events. Anemia after surgery represents an area for prevention. Blood conservation strategies can be performed with adequate results. Monk et al randomized 79 patients undergoing radical prostatectomy to preoperative autologous donation (PAD), preoperative exogenous erythropoietin therapy plus ANH immediately following induction of general anesthesia, and ANH alone. This study concluded that all three techniques resulted in similar hemostasis outcomes

Topics: Anemia; Blood Loss, Surgical; Critical Illness; Erythrocyte Transfusion; Erythropoiesis; Erythropoietin; Humans; Inflammation; United States

Preoperative anemia in a surgical patient predisposes to poor outcomes and allogeneic blood transfusions. As an alternative to transfusions, pharmacologic management of preoperative anemia with recombinant human erythropoietin (rHuEPO) has been well studied in many different types of surgery. rHuEPO, when used alone or in combination with preoperative autologous blood donation before elective surgery, stimulates erythropoiesis and helps to avoid or reduce the need for allogeneic blood transfusions. The clinical evidence on preoperative use of rHuEPO in orthopedic, cardiac, and cancer surgery, as well as in bloodless surgery, is reviewed.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Cardiovascular Diseases; Erythropoietin; Humans; Monitoring, Intraoperative; Neoplasms; Premedication; Recombinant Proteins; Treatment Outcome

Spine surgery may be associated with profuse intraoperative bleeding that often requires blood transfusions. In recent years several techniques have been developed to avoid allogenic transfusions and their potential complications to surgical patients. In this study we review and analyse the role of preoperative recombinant human erythropoietin (rHuEPO) administration in spine surgery as a blood conservation strategy. Between 1998 and 2002, a total of 250 patients scheduled for spine surgery were included in our blood-sparing program: 114 patients (group 1), operated on before rHuEPO approval (2000), underwent preoperative autologous blood donation (ABD) alone, and 136 patients operated on after rHuEPO approval (groups 2 and 3) received rHuEPO while undergoing ABD. Adding rHuEPO to ABD resulted in higher haemoglobin and haematocrit values the day of surgery, more ABD units retrieved per patient and, consequently, reduced allogenic transfusion requirements. The effectiveness of rHuEPO as the only preoperative blood conservation technique was evaluated in ten patients with a predicted blood loss of less than 30% of their total volume, scheduled for lumbar surgery. Data from these patients were matched with those from a similar group of patients who had undergone ABD. Patients receiving rHuEPO alone had higher haemoglobin levels the day of surgery than did patients in the ABD program. Neither group required allogenic transfusions.. preoperative rHuEPO is useful for reducing allogenic blood requirements in elective spine surgery. In patients with an expected blood loss of around 50% of blood volume, rHuEPO improves ABD, minimising preoperative anaemia and increasing the number of ABD units collected. In patients with expected blood loss below 30% of total volume, rHuEPO administration may replace ABD.

Topics: Adolescent; Adult; Aged; Blood Coagulation; Blood Loss, Surgical; Blood Transfusion, Autologous; Blood Viscosity; Case-Control Studies; Erythropoietin; Female; Hemoglobins; Humans; Male; Middle Aged; Recombinant Proteins; Spine

Patients undergoing treatment for infected hip and knee replacements often have significant blood loss and require allogeneic blood transfusions. In the setting of sepsis, traditional methods of blood management such as preoperative blood donations, cell savers, and reinfusion drains are contraindicated. Pharmacologic agents can minimize transfusion requirements by increasing erythropoiesis, or minimize perioperative blood loss. This article reviews the use of these agents in the management of patients with deep prosthetic hip and knee infections.

Topics: Antifibrinolytic Agents; Arthroplasty, Replacement; Blood Loss, Surgical; Blood Transfusion; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Prosthesis-Related Infections; Recombinant Proteins; Reoperation

Recombinant human erythropoietin (rHuEPO) and intravenous (i.v.) iron administration may be useful tools to save blood in surgery. In the perioperative period, rHuEPO should be used in slightly anemic patients for whom an autologous predonation program is not recommended (or feasible). In such cases, i.v. iron is only given if there is a functional or real iron deficiency state. In the post-operative period, i.v. iron is administered in association with rHuEPO in an attempt to rapidly correct severe post-operative anemia. The same regimen is used for patients undergoing surgery for inflammatory bowel disease and rheumatoid arthritis. Finally, other particular categories of patients, such as those with reduced body weight (< 50 kg), candidates for surgery with increased blood needs (> 5 units), or those with a too-short period of time before surgery, also benefit from the administration of these two drugs.

Topics: Administration, Oral; Adolescent; Adult; Aged; Anemia; Arthritis, Rheumatoid; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hemoglobins; Humans; Inflammatory Bowel Diseases; Infusions, Intravenous; Iron; Iron Deficiencies; Postoperative Care; Postoperative Complications; Preoperative Care; Randomized Controlled Trials as Topic; Recombinant Proteins; Risk Factors; Surgical Procedures, Operative; Time Factors

Topics: Blood Loss, Surgical; Blood Substitutes; Erythropoietin; Humans; Iron; Perioperative Care; Transfusion Reaction

The transfusion of red blood cells is still associated with possible adverse effects and a residual risk of transmission of viral and nonviral diseases. In addition, there is an increasing shortage of blood supply worldwide. These two facts together with the success experienced in the treatment of various types of anemia with recombinant human EPO, have recently led to an increasing interest in the anemia of critically ill patients. As in the anemia of chronic diseases there are several reasons that contribute to the development of anemia in patients on intensive care units: pre-existing anemia, blood loss, reduced red cell life span, impaired iron availability and a direct inhibition of erythropoiesis by inflammatory cytokines. The implications of anemia for the progression and prognosis of critical illness are still unclear and the optimal treatment, including optimal "transfusion triggers" remains controversial. Recombinant human EPO has been proven to be effective in ameliorating the anemia of critical illness in several pilot studies and is currently being tested in larger trials.

Topics: Adult; Anemia; Blood Loss, Surgical; Child; Critical Care; Critical Illness; Cytokines; Double-Blind Method; Drug Therapy, Combination; Erythrocyte Transfusion; Erythropoiesis; Erythropoietin; Hemoglobins; Humans; Iron Compounds; Jehovah's Witnesses; Middle Aged; Multicenter Studies as Topic; Pilot Projects; Placebos; Randomized Controlled Trials as Topic; Recombinant Proteins; Reticulocyte Count; Time Factors; Transfusion Reaction

The principle aim of "bloodless surgery" is to minimize blood loss and to reduce or eliminate exposure to allogeneic blood transfusion. The risks associated with blood transfusions have been well documented, and it is the goal of bloodless surgery centers to avoid complications and unnecessary use of blood. Blood transfusion is a significant adjunct to perioperative resuscitation. However, we aim to elucidate different approaches to minimizing blood loss and avoiding transfusion.. In this document, we review the background and current status of bloodless surgery centers and then the different approaches to achieve the program goals.. There is no one single universal blood conservation strategy that is applicable to all patients and populations. Factors such as preexisting disease will alter the approach; however, it is the ability of any program to form a comprehensive strategy for blood conservation that is integral to the success of any such program.. The success of a bloodless surgery program requires both teamwork and careful cooperation between the blood bank, pharmacy, administration, hematologists, surgeon, and anesthesiologist to ensure that the goals of minimizing blood loss and avoiding transfusion are met.

Topics: Anesthesia; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Humans; Perioperative Care; Risk Assessment; Surgical Procedures, Operative

Topics: Blood Loss, Surgical; Blood Substitutes; Blood Transfusion, Autologous; Contraindications; Erythropoietin; Fluorocarbons; Hemodilution; Humans; Plasma Substitutes; Recombinant Proteins

There is still no alternative that is as effective or as well tolerated as blood; nevertheless, the search for ways to conserve, and even eliminate blood transfusion, continues. Based on hemoglobin levels, practice guidelines for the use of perioperative transfusion of red blood cells in patients undergoing coronary artery bypass grafting have been formulated by the National Institutes of Health and the American Society of Anesthesiologists. However, it has been argued that more physiologic indicators of adequacy of oxygen delivery should be used to assess the need for blood transfusion. Methods used for conserving blood during surgery include autologous blood donation, acute normovolemic hemodilution and intra- and postoperative blood recovery and reinfusion. The guidelines for the use of autologous blood transfusion are controversial and it does not appear to be cost effective compared with allogeneic blood transfusion in patients undergoing cardiac surgery. Similarly, the cost effectiveness of intra- and postoperative blood recovery and reinfusion need further evaluation. Treatment with recombinant human erythropoietin (rhEPO) remains unapproved in the US for patients undergoing cardiac or vascular surgery, but it is a valuable adjunct in Jehovah's Witness patients, for whom blood is unacceptable. The characterization of darbepoetin alfa, a novel erythropoiesis stimulating protein with a 3-fold greater plasma elimination half-life compared with rhEPO, is an important advance in this field. Darbepoetin alfa appears to be effective in treating the anemia in patients with renal failure or cancer and trials in patients with surgical anemia are planned. Desmopressin has been used to effectively reduce intraoperative blood loss. Topical agents to prevent blood loss, such as fibrin glue and fibrin gel, and agents that alter platelet function, such as aspirin (acetylsalicylic acid) or dipyridamole, need further evaluation in patients undergoing cardiac surgery. Aprotinin has been shown to preserve hemostasis and reduce allogeneic blood exposure to a greater extent than the antifibrinolytic agents tranexamic acid and aminocaproic acid. Controlled clinical trials comparing the costs of these agents with clinical outcomes, along with tolerability profiles in patients at risk for substantial perioperative bleeding are needed.

Topics: Blood Loss, Surgical; Blood Specimen Collection; Blood Transfusion; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Clinical Trials as Topic; Critical Care; Erythropoietin; Hemodilution; Hemostasis, Surgical; Humans; Intraoperative Care; Postoperative Care; Recombinant Proteins

Hysterectomy is the second-most-common surgical procedure among premenopausal women. The conditions that lead to the need for a hysterectomy often are accompanied by chronic blood loss that can lead to anemia. Moreover, hysterectomy and myomectomy may result in significant blood loss, which exacerbates the anemia. The presence of fatigue associated with anemia has a substantially negative impact on quality of life and the ability to perform activities of daily living. Options for alleviating perioperative anemia include minimizing surgical blood loss, blood transfusion, supplementation with hematinics, such as iron and folic acid, and treatment with recombinant human erythropoietin. Treating preoperative anemia is expected to help correct anemia prior to surgery and may have a positive impact on anemia-related symptoms and surgical outcomes.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Fatigue; Female; Gonadotropin-Releasing Hormone; Gonadotropins; Hematinics; Hematocrit; Humans; Hysterectomy; Preoperative Care; Recombinant Proteins

Topics: Algorithms; Aprotinin; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiopulmonary Bypass; Coronary Artery Bypass; Erythropoietin; Evidence-Based Medicine; Female; Hematocrit; Hemodilution; Hemostasis, Surgical; Humans; Hypoxia-Ischemia, Brain; Intraoperative Complications; Male; Multicenter Studies as Topic; Premedication

There are a number of problems with allogeneic blood transfusion. Some of these problems are defined and can be quantified, such as the problem of rising cost or the risk of viral infection, but some of the problems are not well defined and it is only outcome data that point to allogeneic blood transfusion contributing to patient mortality and morbidity. Autotransfusion includes any technique in which the patient's own blood is collected, processed and stored, followed by reinfusion when circumstances dictate. In the perioperative period of cardiac surgery, a number of techniques are recognized as useful in this context. Preoperative autologous donation, with or without erythropoietin supplementation, intraoperative acute normovolaemic haemodilution, intraoperative cell salvage, postoperative cell salvage (reinfusion of shed mediastinal blood) and platelet rich plasmapheresis are all techniques which are used with more or less enthusiasm to reduce the need for an allogeneic blood transfusion. Modification of the priming technique of the cardiopulmonary bypass circuit using an autologous blood prime is included in this review even though it does not fall strictly within the definition of autotransfusion. Although autotransfusion is not the answer to every problem, there is no doubt that it should play a significant part in the strategy of blood conservation.

Topics: Blood Loss, Surgical; Blood Preservation; Blood Transfusion; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Cost-Benefit Analysis; Costs and Cost Analysis; Elective Surgical Procedures; Equipment Design; Erythropoietin; Hemodilution; Humans; Infections; Intraoperative Care; Length of Stay; Mediastinum; Multicenter Studies as Topic; Patient Selection; Plasmapheresis; Platelet Transfusion; Transfusion Reaction; United Kingdom

Topics: Acute Disease; Anemia; Blood Loss, Surgical; Cell Division; Erythrocytes; Erythroid Precursor Cells; Erythropoietin; Humans; Iron

Topics: Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Blood Transfusion, Autologous; Blood-Borne Pathogens; Epoetin Alfa; Erythropoietin; Female Urogenital Diseases; Hemodilution; Humans; Male Urogenital Diseases; Recombinant Proteins; Transfusion Reaction; Utilization Review

The aim of all efforts to reduce the need of allogeneic blood transfusions is to avoid associated risks. There should particularly be a favourable effect according to the rate of transfusion-transmitted virus infections and immunological side-effects. The acceptance of an individually adjusted lowest haematocrit level and the minimisation of intra-operative blood loss by the application of optimal surgical techniques are among the most essential strategies to reduce or even avoid allogeneic blood transfusions. In addition the following interventions are generally accepted: Preoperative autologous blood donation, where appropriate supported by erythropoietin Preoperative haemodilution, where appropriate supported by erythropoietin Intra- and postoperative blood salvage Topical or systemic pharmacologic interventions to accelerate haemostasis Controlled hypotension Efficacy and indication of the different measures always depend on the individual circumstances of the specific patient. Therefore one should develop an individual approach for every case. In this context the most important subjects are an optimal coordination and if required an appropriate combination of the discussed methods. Algorithms which preoperatively allow approximate calculation of expected transfusion need may be a meaningful tool to facilitate blood conservation planning. However, at the same time one must consider that all strategies to reduce allogeneic transfusion needs are also associated with particular risks. Therefore one has to weigh carefully the pros and cons prior to their application, including the possible alternative of allogeneic transfusion in one's decision making process.

Topics: Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Erythropoietin; Hemodilution; Humans; Recombinant Proteins

Topics: Animals; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion, Autologous; Communicable Diseases; Erythrocyte Transfusion; Erythropoietin; Hemodilution; Humans; Preoperative Care; Transplantation, Homologous

Topics: Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hemodilution; Humans; Plasma; Recombinant Proteins; Wounds and Injuries

Preoperative hemoglobin concentration may be an important predictor of transfusion risk in surgical procedures with significant expected blood loss. Contemporary studies investigating transfusion risk with regard to the relationship between perioperative administration of Epoetin alfa and baseline hemoglobin provide data to test this hypothesis. The predictive power of seven preoperative variables (hemoglobin concentration, age, erythropoietin level, ferritin concentration, serum iron, total iron-binding capacity, and predicted blood volume) on transfusion risk was examined via retrospective logistic regression analysis of 276 orthopedic surgical patients. In the two studies used to perform the regression analysis, patients were treated daily with either Epoetin alfa or placebo. Based on the retrospective analyses, a prospective study was conducted to validate the hypothesis. Of the seven variables evaluated, baseline hemoglobin concentration and predicted blood volume were significantly predictive of transfusion risk in both Epoetin alfa- and placebo-treated patients. Further, an inverse correlation between hemoglobin concentration and transfusion risk was demonstrated in placebo-treated patients. Placebo-treated patients with hemoglobin > 10 to < or = 13 g/dL had an approximately twofold greater risk of transfusion than patients with hemoglobin > 13 g/dL. In contrast to placebo treatment, Epoetin alfa significantly reduced transfusion risk in patients with hemoglobin > 10 to < or = 13 g/dL. Baseline hemoglobin concentration is an excellent predictor of transfusion risk in orthopedic surgical patients. As a result, hemoglobin testing should be considered a part of routine preoperative testing for orthopedic surgical patients.

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Double-Blind Method; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hematocrit; Hemoglobins; Humans; Male; Multicenter Studies as Topic; Placebos; Prospective Studies; Randomized Controlled Trials as Topic; Recombinant Proteins; Regression Analysis; Retrospective Studies; Risk Factors

Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Humans; Orthopedics; Recombinant Proteins

The amount of transfused blood is related to blood loss calculated for the specific type of surgical procedure, transfusion hematocrit trigger and patient's red blood cell mass on the day before surgery. To optimise the benefit/cost and benefit/risk ratios of blood transfusion, a correct prescription must be done in accordance with the patient's red blood cell mass and surgical blood loss. Indeed, there is a clear need to define the appropriate uses of blood management methods and to seek new methods of improving perioperative blood management. The number of moderately anaemic patients undergoing surgery is currently thought to be 20%. Where transfusion requirements are estimated at two to three blood units, as for instance in the most common types of orthopaedic surgery, preoperative haemoglobin is the key factor governing transfusion needs. In this case, the simplest approach is to prescribe Epoetin Alfa subcutaneous at a dose of 600 IU/kg/week starting three weeks before the surgery. In addition, it is important in all cases to give concomitant iron supplements. Concomitant use of other methods to decrease allogeneic blood requirements is of no value. Obviously, the higher the haematocrit the day prior to surgery, the higher the patient's RBC mass and the greater the patient's permitted blood loss, decreasing the transfusion trigger. In this way, allogeneic blood loss is reduced, but without the need for the patient to attend the blood transfusion center and to undergo laboratory screening and testing of donated blood, and without the risk of inducing preoperative anaemia compared with sequential autologous blood donation. But, to optimise the benefit/cost ratio, we try to define precisely the patient populations likely to benefit from preoperative erythropoietin. Using different examples, management is proposed with algorithms.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Comorbidity; Cost-Benefit Analysis; Epoetin Alfa; Erythropoietin; Evaluation Studies as Topic; Hematocrit; Humans; Infusions, Intravenous; Intraoperative Care; Iron; Multicenter Studies as Topic; Orthopedics; Premedication; Preoperative Care; Recombinant Proteins

Topics: Blood Banks; Blood Loss, Surgical; Blood Transfusion, Autologous; Contraindications; Erythropoietin; HIV Infections; HIV Seropositivity; Humans; Medical Errors; Recombinant Proteins; Risk Assessment; Safety

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoiesis; Erythropoietin; Humans; Preoperative Care; Randomized Controlled Trials as Topic; Recombinant Proteins

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.

Topics: Blood Loss, Surgical; Erythropoietin; Fractures, Bone; Hip Fractures; Humans; Pelvis

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoiesis; Erythropoietin; Hemodilution; Humans; Postoperative Complications

Topics: Adult; Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoiesis; Erythropoietin; Feedback; Hematologic Diseases; Humans; Infant, Newborn; Iron Deficiencies; Kidney; Neoplasms; Recombinant Proteins; Uremia

To avoid the inherent risk of complications associated with perioperative allogeneic transfusion, preoperative autologous blood donation (PAD) is frequently employed by patients undergoing major elective surgical procedures. However, many patients are unable to donate a sufficient quantity of blood prior to surgery. Recent studies have shown that epoetin alfa (Procrit; Ortho-Biotech, Raritan, NJ) effectively increases red blood cell (RBC) mass when administered preoperatively and decreases the requirement for allogeneic transfusion. These studies also demonstrated that patients with baseline hemoglobin levels ranging from 10 to 13 g/dL have the highest risk for requiring allogeneic transfusions and appear to achieve the greatest benefit from epoetin alfa treatment. We evaluated several dosing regimens and schedules for perioperative epoetin alfa administration. In our initial study, the comparative efficacy of three different epoetin alfa regimens was assessed by hemoglobin concentration, hematocrit, and absolute reticulocyte counts. In addition, we analyzed the effect of accelerated erythropoiesis on iron indices and individual RBC hemoglobin content. Our study demonstrated that epoetin alfa is safe and effective in increasing RBC mass; however, iron stores considered sufficient for basal erythropoiesis may not optimally support the accelerated RBC production associated with epoetin alfa therapy. In a subsequent randomized multicenter trial, we compared weekly epoetin alfa dosing to daily dosing in patients undergoing elective major orthopedic surgery. The results of this study indicated that administering epoetin alfa on a weekly schedule for several weeks prior to surgery may be at least as effective and more convenient than perioperative daily epoetin alfa dosing.

Topics: Blood Loss, Surgical; Blood Transfusion; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Randomized Controlled Trials as Topic; Recombinant Proteins; Transfusion Reaction; Transplantation, Autologous; Transplantation, Homologous

'Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.

Topics: Blood Loss, Surgical; Christianity; Contraindications; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Male; Middle Aged; Recombinant Proteins; Surgical Procedures, Operative; Transfusion Reaction; United States

Blood conservation has evolved into an important issue in hospital-based medicine. Increased awareness of and worry about transfusion-associated diseases have prompted a focus on this important area. New technologies, including continuous intraarterial monitoring devices, microchemical technologies, new drug development (recombinant human erythropoietin and aprotinin) and intraoperative salvage techniques have made the concept of clinically important blood conservation possible. In this article, the authors review clinically important areas regarding blood conservation, which are subsequently detailed in this issue of AACN Clinical Issues. Emphasis is placed on the need for blood conservation in acute and critical care practice and the technologies available to achieve this goal.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Critical Care; Erythropoietin; Humans

The introduction of autologous blood (AB) donation programs has led to a decrease in the number of orthopedic surgery patients exposed to allogeneic blood, although there is still room for improvement. For example, some patients may not be able to donate sufficient AB to meet their expected blood requirements. Virtually all nonanemic patients can donate 3 AB units prior to orthopedic surgery before further AB donation is limited by the development of anemia. In preliminary studies, the administration of epoetin alfa (150 IU/kg subcutaneously (s.c.) on alternate days; six doses) following the donation of 3 AB units reversed phlebotomy-induced anemia and enabled a further 2 units of AB to be collected. The ability of this therapeutic approach to increase AB procurement and reduce allogeneic blood requirements is being investigated in an ongoing, placebo-controlled study. An alternative approach may be to combine perisurgical treatment with epoetin alfa and normovolemic hemodilution (NVHD) prior to orthopedic surgery. Although such studies have yet to be initiated, they may demonstrate a reduction in allogeneic blood exposure in patients unable to donate AB prior to orthopedic surgery, a group of patients traditionally at high risk of exposure to allogeneic blood.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Blood Volume; Clinical Trials as Topic; Epoetin Alfa; Erythropoiesis; Erythropoietin; Hemodilution; Humans; Orthopedics; Premedication; Recombinant Proteins

Topics: Adolescent; Blood Group Incompatibility; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Child; Child, Preschool; Disease Transmission, Infectious; Erythropoietin; Female; Humans; Infant; Male; Orthopedics; Patient Care Planning; Transfusion Reaction; Vasopressins

A Roundtable of Experts in Surgery Blood Management was held 7 to 9 April 1995, in Vienna, where all the available published and unpublished epoetin alfa clinical data was thoroughly discussed and where the following CONSENSUS STATEMENT was developed to give the clinician some practical guidelines for the administration of epoetin alfa in elective surgery patients.. For elective surgery patients it is important to facilitate, via blood conservation methods, the elimination or reduction of exposure to allogeneic blood transfusion and its associated risks. Adjunctive use of epoetin alpha therapy in specific patients is one method to accomplish this goal. Patients with small body size, predicted low blood volume (< or = 51), and/or a hematocrit too low to be enrolled in or to complete their prescribed ABD (autologous blood donation) program especially benefit from epoetin alfa therapy. Generally, epoetin alfa therapy is well tolerated, with an acceptable risk-to-benefit ratio.

Topics: Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Blood-Borne Pathogens; Dose-Response Relationship, Drug; Drug Administration Schedule; Erythropoietin; Humans; Recombinant Proteins

The role of iron metabolism, the value and the limits of oral as well as intravenous iron substitution in preoperative autologous blood donation are discussed according to the literature.. The critical review of the German and English literature is based on a Medline backsearch covering the last 20 years.. The success of preoperative autologous blood donation substantially depends on the volume of whole-body iron and on the amount of storage iron which is available at the beginning of the donation phase. Since iron losses due to repeated blood donations within a few weeks cannot be replaced sufficiently by food, medical iron substitution seems to be appropriate. Nevertheless, hitherto neither oral nor intravenous iron substitution could be demonstrated as useful instruments for an improvement of erythropoietic response in non iron deficient patients after autologous blood donation. Merely, intravenous iron used in combination with recombinant erythropoietin seems to be an effective support for erythropoiesis during predeposit.. At the moment intravenous iron medication in autologous blood donation should be restricted to well-established exceptional cases. The use of intravenous iron combined with erythropoietin seems to be justified to avoid ineffective erythropoieses and to achieve a dose reduction of recombinant erythropoietin. Since there are nearly no risks and a possible efficacy cannot be totally excluded, oral iron supplementation may be applied to patients who tolerate it well. Real iron deficiency has to be treated with iron application. Further clinical studies have to be done for a final validation of the efficacy of iron substitution in non iron deficient preoperative autologous blood donors.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Blood Volume; Erythropoiesis; Erythropoietin; Homeostasis; Humans; Iron; Preoperative Care; Recombinant Proteins

Topics: Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Recombinant Proteins

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Hemoglobinometry; Humans; Recombinant Proteins; Treatment Refusal

Pharmacological stimulation of erythropoiesis was studied in patients selected for open heart surgery, and undergoing a programme of autologous blood predonation prior to surgery. Sixteen patients (group I: ery) received 4000 I. U. of recombinant human erythropoietin (r-huepo) subcutaneously weekly three times during a 3-week period preoperatively, another group of 21 patients (group II: control) were not given r-huepo. Patients in both groups received orally 2 x 80 mg iron daily. Predonation of five units of blood was planned in each patients, beginning on the 21. preoperative day; no blood was taken from patients if the hematocrit dropped below 0.34, or if any other complications occurred. The average amount of blood taken from patients in the ery group was 4.8 +/- 0.4 Units, and in the control group: 3.7 +/- 1.1 Units. In the ery group the planned 5 Units of blood could be taken from 13/16 patients, while in the controls only from 7/21. The differences are statistically significant. Reticulocyte counts were significantly higher consecutively during the preoperative period in the ery group than in the controls. In the postoperative period erythropoiesis was less pronounced in the ery group than in the controls. It is concluded that 1. r-huepo is an effective drug in preventing (or reducing) the anaemia due to repeated preoperative blood withdrawals, and thus larger amounts of autologous blood will be available for predonation. 2. More pronounced decrease of circulating reticulocytes observed in the postoperative period points to a possible suppression of endogenous erythropoietin production in the ery group.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Erythropoiesis; Erythropoietin; Female; Hematocrit; Humans; Male; Middle Aged; Postoperative Period; Recombinant Proteins

After rapid changes in transfusion practice over the past few years, blood conservation techniques have become standard in modern perioperative management. As a result, the amount of homologous blood products transfused has been markedly reduced in some types of surgical procedures. Provided that skillful surgical technique is applied and the use of blood products is restricted, autologous transfusion techniques (predonation of autologous blood, preoperative plasmapheresis, acute normovolaemic haemodilution, and intra- and postoperative blood salvage) can be performed with an acceptable risk for patients. In addition, stimulation of erythropoiesis with recombinant human erythropoietin, supplemental iron therapy, and improving haemostasis by aprotinin may further reduce homologous blood requirements. All patients undergoing elective surgery have to be informed about the side effects of transfusion of homologous blood products and the possibility of blood-saving methods. An individual blood conservation plan, based on the patient's status and surgery, the equipment available, and personal experience should be worked out by the responsible anaesthesiologist, whereby a combination of different methods may be most effective. If storage is necessary, autologous blood products should be preparated like homologous products. The feasibility of predonation and retransfusion of autologous blood in patients with infectious diseases like hepatitis or acquired immune deficiency syndrome and the amount of labaratomy testing are still under discussion. Although blood conservation programs are time-consuming and more expensive, they reduce the various risks of using homologous blood products.

Topics: Adolescent; Adult; Blood Coagulation Tests; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Child; Child, Preschool; Christianity; Erythropoietin; Hemodilution; Humans; Infant; Infant, Newborn; Recombinant Proteins

Approximately 12 million red blood cell units are transfused to nearly 4 million patients annually in the United States (1). The conservation of blood has historically arisen from awareness that the inventory of this resource is limited (2), as well as the knowledge that blood transfusion carries a risk (3). Estimates of current blood transfusion risks (4-12), and the costs of transfusion complications (13-17), are summarized in Table 1. In addition, emphasis on the costs of health care has raised issues related to the costs of blood transfusion (18, 19). Finally, recent guidelines have emphasized that in the elective transfusion setting, no blood transfusion is a desirable outcome (20, 21). Furthermore, these guidelines along with consensus conference recommendations (22) have emphasized that if blood is to be transfused, autologous (the patient's own) blood is preferable to allogeneic (from an anonymous, volunteer donor) blood. Thus, the costs of blood conservation, for which an increasing array of technologic procedures and products have become available (Table 2), have also become an issue (23). The purpose of this review is to provide an overview of emerging data on the cost-effectiveness of blood and blood conservation interventions in order to help identify areas important for future investigation.

Topics: Blood Loss, Surgical; Blood Preservation; Blood Specimen Collection; Blood Transfusion; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoietin; Female; Guidelines as Topic; Hemodilution; Hospital Costs; Humans; Male; Risk Factors; United States; Utilization Review

Topics: Blood Banks; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Coronary Artery Bypass; Cost-Benefit Analysis; Erythropoiesis; Erythropoietin; Hospitals, University; Humans; Intraoperative Care; Missouri

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythrocyte Indices; Erythropoiesis; Erythropoietin; Humans; Orthopedics; Recombinant Proteins

Topics: Aprotinin; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiovascular Surgical Procedures; Deamino Arginine Vasopressin; Erythropoietin; Humans; Iron; Plasmapheresis

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

Topics: Animals; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Humans; Hypotension, Controlled; Intraoperative Care; Recombinant Proteins; Spine

Topics: Aprotinin; Blood Loss, Surgical; Blood Substitutes; Erythropoietin; Humans; Recombinant Proteins

Topics: Acquired Immunodeficiency Syndrome; Adult; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Erythropoiesis; Erythropoietin; Evaluation Studies as Topic; Female; Humans; Male; Postoperative Care; Preoperative Care; Recombinant Fusion Proteins; Surgical Procedures, Operative; Transfusion Reaction; Treatment Refusal

The purpose of study is to evaluate the effect and complication of preoperative short-term daily recombinant human erythropoietin (rhEPO) treatment for blood-saving in patients undergoing unilateral primary total knee arthroplasty (TKA).. This three-arm randomized clinical trial compared three different rhEPO-based treatment protocols for unilateral primary TKA. Group A: application of daily doses of rhEPO combined with iron supplement starting 3 days before surgery; Group B: application of daily doses of rhEPO combined with iron supplement starting the day of surgery; Group C: iron supplement alone. Perioperative hemoglobin (Hb) level gaps, total perioperative blood loss, reticulocyte levels and treatment-related complications were studied.. A total of 102 patients were included (35, 35 and 32 patients in Groups A, B and C, respectively). Total blood loss (TBL) in Groups A, B and C was 490.84, 806.76 and 924.21 ml, respectively. Patients in Group A had a significant lower TBL than Groups B and C (A vs. B: P = 0.010; A vs. C: P < 0.001). There was no difference as for TBL between Groups B and C (P = 0.377). Group A patients had significant smaller Hb decline than Group C on the third and fifth postoperative day (P = 0.049, P = 0.037), as well as than Group B on the fifth postoperative day (P = 0.048). There was no difference as for Hb decline between Groups B and C. No difference was shown in levels of inflammatory biomarkers or blood-saving protocol-related complications among three groups.. Daily dose of rhEPO combined with iron supplement administered 3 days before TKA procedures could significantly decrease perioperative blood loss and improve postoperative Hb levels, without significantly elevating risks of complication, when compared with admission of rhEPO on the day of surgery and iron supplement alone. Preoperative daily rhEPO treatment could be a more effective blood-saving protocol in TKA procedures.

Topics: Aged; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Dietary Supplements; Erythropoietin; Female; Humans; Iron; Male; Middle Aged; Preoperative Care; Recombinant Proteins; Treatment Outcome

Children with craniosynostosis may require cranial vault remodeling to prevent or relieve elevated intracranial pressure and to correct the underlying craniofacial abnormalities. The procedure is typically associated with significant blood loss and high transfusion rates. The risks associated with transfusions are well documented and include transmission of infectious agents, bacterial contamination, acute hemolytic reactions, transfusion-related lung injury, and transfusion-related immune modulation. This study presents the Children's Hospital of Richmond (CHoR) protocol, which was developed to reduce the rate of blood transfusion in infants undergoing primary craniosynostosis repair.. A retrospective chart review of pediatric patients treated between January 2003 and Febuary 2012 was performed. The CHoR protocol was instituted in November 2008, with the following 3 components; 1) the use of preoperative erythropoietin and iron therapy, 2) the use of an intraoperative blood recycling device, and 3) acceptance of a lower level of hemoglobin as a trigger for transfusion (< 7 g/dl). Patients who underwent surgery prior to the protocol implementation served as controls.. A total of 60 children were included in the study, 32 of whom were treated with the CHoR protocol. The control (C) and protocol (P) groups were comparable with respect to patient age (7 vs 8.4 months, p = 0.145). Recombinant erythropoietin effectively raised the mean preoperative hemoglobin level in the P group (12 vs 9.7 g/dl, p < 0.001). Although adoption of more aggressive surgical vault remodeling in 2008 resulted in a higher estimated blood loss (212 vs 114.5 ml, p = 0.004) and length of surgery (4 vs 2.8 hours, p < 0.001), transfusion was performed in significantly fewer cases in the P group (56% vs 96%, p < 0.001). The mean length of stay in the hospital was shorter for the P group (2.6 vs 3.4 days, p < 0.001).. A protocol that includes preoperative administration of recombinant erythropoietin, intraoperative autologous blood recycling, and accepting a lower transfusion trigger significantly decreased transfusion utilization (p < 0.001). A decreased length of stay (p < 0.001) was seen, although the authors did not investigate whether composite transfusion complication reductions led to better outcomes.

Topics: Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Craniosynostoses; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hemoglobins; Humans; Infant; Intraoperative Period; Male; Medical Records; Recombinant Proteins; Retrospective Studies; Sample Size

Surgical correction of craniosynostosis in children is associated with substantial intraoperative bleeding. Tranexamic acid (TXA) decreases intraoperative blood loss during cardiac or orthopedic surgery in children. We hypothesized that intraoperative TXA would reduce blood transfusion relative to placebo in patients pretreated with erythropoietin.. Forty consecutive children, American Society of Anesthesiologists status 1 or 2, scheduled to undergo surgical correction of craniosynostosis were randomly assigned to receive either intravenous TXA or saline, 0.9%, intraoperatively. All children received preoperative erythropoietin (600 U/kg once a week for 3 weeks before surgery). Perioperative blood loss, number and volume of transfusions, percentage of children who underwent transfusion, and side effects were noted after surgery and at the end of the study. Surgeon satisfaction and cost of treatment were also recorded.. There was no significant difference between groups in demographic or surgical data. In the TXA group, the volume of packed erythrocytes transfused was significantly reduced by 85% (from 11 to 1.6 ml/kg) intraoperatively and by 57% (from 16.6 to 7.2 ml/kg) throughout the study period (P < 0.05). Compared with the placebo group, the percentage of children requiring blood transfusion was lower in the TXA group during surgery (9 [45%] of 20 vs. 2 [11%] of 19 children; P < 0.05) and during the whole study period (14 [70%] of 20 vs. 7 [37%] of 19; P < 0.05). Preoperative and postoperative hematologic parameters were comparable in both groups. There were no adverse events.. In children undergoing surgical correction of craniosynostosis and pretreated with erythropoietin, intraoperative TXA reduces the transfusion requirement.

Topics: Adolescent; Antifibrinolytic Agents; Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Craniosynostoses; Double-Blind Method; Erythropoietin; Female; Humans; Intraoperative Care; Male; Tranexamic Acid; Treatment Outcome

Preoperative anaemia is a major risk factor for allogeneic blood transfusion (ABT) in patients undergoing hip fracture repair. We investigated the efficacy of preoperative recombinant human erythropoietin (rHuEPO) administration for reducing ABT requirements in a series of consecutive hip fracture patients presenting with haemoglobin (Hb) between 10 g/dl and 13 g/dl.. The blood conservation protocol consisted of the application of a restrictive transfusion trigger (Hb < 8 g/dl) and the perioperative administration of intravenous iron sucrose (3 x 200 mg/48 h) (group 1, n = 115). Additionally, some patients received preoperative rHuEPO (40 000 IU sc) on admission to the orthopaedic ward (group 2, n = 81).. Overall, 103 of 196 patients (52.5%) received at least one ABT unit (2.1 +/- 1.0 U/patient). However, there were significant differences in perioperative ABT rates between groups (60% vs. 42%, for groups 1 and 2, respectively; P = 0.013). Postoperative Hb on postoperative days 7 and 30 was higher in group 2 than in group 1. In addition, in group 2, Hb levels were higher on postoperative day 30 than on admission (12.7 +/- 1.0 g/dl vs. 11.9 +/- 0.8 g/dl, respectively; P = 0.030). Administration of rHuEPO did not increase postoperative complications or 30-day mortality rate. Only three mild intravenous iron adverse effects were witnessed.. In anaemic hip fracture patients managed with perioperative intravenous iron and restrictive transfusion protocol, preoperative administration of rHuEPO is associated with reduced ABT requirements. However, appropriate training, education and awareness are needed to avoid protocol violations and to limit further exposure to ABT and ABT-related risks.

Topics: Aged; Aged, 80 and over; Ascorbic Acid; Blood Loss, Surgical; Blood Transfusion; Epoetin Alfa; Erythropoietin; Female; Ferric Compounds; Ferric Oxide, Saccharated; Folic Acid; Fracture Fixation, Internal; Glucaric Acid; Guideline Adherence; Hip Fractures; Hospitals, University; Humans; Male; Postoperative Complications; Premedication; Prospective Studies; Recombinant Proteins; Retrospective Studies; Vitamin B 12

This prospective randomised clinical trial evaluated the effect of alternatives for allogeneic blood transfusions after total hip replacement and total knee replacement in patients with pre-operative haemoglobin levels between 10.0 g/dl and 13.0 g/dl. A total of 100 patients were randomly allocated to the Eprex (pre-operative injections of epoetin) or Bellovac groups (post-operative retransfusion of shed blood). Allogeneic blood transfusions were administered according to hospital policy. In the Eprex group, 4% of the patients (two patients) received at least one allogeneic blood transfusion. In the Bellovac group, where a mean 216 ml (0 to 700) shed blood was retransfused, 28% (14 patients) required the allogeneic transfusion (p = 0.002). When comparing Eprex with Bellovac in total hip replacement, the percentages were 7% (two of 30 patients) and 30% (nine of 30 patients) (p = 0.047) respectively, whereas in total knee replacement, the percentages were 0% (0 of 20 patients) and 25% (five of 20 patients) respectively (p = 0.042). Pre-operative epoetin injections are more effective but more costly in reducing the need for allogeneic blood transfusions in mildly anaemic patients than post-operative retransfusion of autologous blood.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hemostasis, Surgical; Humans; Injections; Male; Middle Aged; Postoperative Care; Preoperative Care; Prospective Studies; Recombinant Proteins; Statistics as Topic

Craniosynostotic correction typically performed around infant physiologic nadir of hemoglobin (approximately 3-6 months of age) is associated with high transfusion rates of packed red blood cells and other blood products. As a blood conserving strategy, we studied the use of 1) recombinant human erythropoietin or Procrit (to optimize preoperative hematocrit) and 2) Cell Saver (to recycle the slow, constant ooze of blood during the prolonged case).. UCLA Patients with craniosynostosis from 2003-2005 were divided into 1) the study group (Procrit and Cell Saver) or 2) the control group (n = 79). The study group 1) received recombinant human erythropoietin at 3 weeks, 2 weeks, and 1 week preoperatively and 2) used Cell Saver intraoperatively. Outcomes were based on morbidities and transfusion rate comparisons.. The 2 groups were comparable with regards to age (5.66 and 5.71 months), and operative times (3.11 vs 2.59 hours). In the study group there was a marked increase in preoperative hematocrit (56.2%). The study group had significantly lower transfusions rates (5% vs 100% control group) and lower volumes transfused than in the control group (0.05 pediatric units vs 1.74 pediatric units). Additionally, of the 80% of patients in the study group who received Cell Saver blood at the end of the case, approximately 31% would have needed a transfusion if the recycled blood were unavailable.. Our data showed that for elective craniosynostotic correction, successful blood conserving dual therapy with Procrit and Cell Saver might be used to decrease transfusion rates and the need for any blood products.

Topics: Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Craniosynostoses; Craniotomy; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Hematinics; Hematocrit; Hemoglobins; Humans; Infant; Injections, Subcutaneous; Intraoperative Care; Plastic Surgery Procedures; Postoperative Complications; Premedication; Recombinant Proteins; Time Factors; Treatment Outcome

Unilateral total knee replacement (TKR) results in a substantial blood loss and 30 to 50 percent of patients receive allogeneic blood transfusion (ABT). Therefore, the effectiveness of a restrictive transfusion trigger (hemoglobin [Hb] level < 8 g/dL) plus stimulation of erythropoiesis was evaluated, with or without blood salvage, for reducing ABT in TKR patients.. A series of 139 consecutive of primary TKR patients received perioperative iron sucrose (2 x 200 mg/48 hr, intravenously [IV]), plus preoperative erythropoietin (EPO; 1 x 40.000 UI, sc) if preoperative Hb level was less than 130 g per L (Group A). This protocol was applied to another series of 173 consecutive TKR patients who also received postoperative unwashed shed blood (USB) if preoperative Hb level was less than 130 g per L (Group B). Perioperative clinical and laboratory data were gathered.. No adverse effects of iron sucrose, EPO, or USB administration were witnessed, and only 13 patients received ABT overall (4%). No major differences in perioperative blood counts or iron metabolism variables were observed between groups, but stimulation of erythropoiesis seemed to be more pronounced in those patients receiving EPO (p < 0.05). There were no differences in postoperative complications between groups, but length of hospital stay for patients with a preoperative Hb level of less than 130 g per L was shorter in Group B (p < 0.05).. This blood saving protocol seems to be effective for reducing ABT in TKR patients. Which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment, however, needs to be further evaluated.

Topics: Aged; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Erythropoiesis; Erythropoietin; Female; Hemoglobins; Humans; Iron; Length of Stay; Male; Perioperative Care; Postoperative Complications; Recombinant Proteins

This prospective randomized trial compared preoperative autologous blood donation (PAD) with epoetin alfa in patients undergoing primary total knee reconstruction. Fifty adult patients with pretreatment hemoglobin level of 100 to 130 g/L were randomized to either epoetin alfa 40,000 U at preoperative days 14 and 7 or to a standard PAD protocol. Patient characteristics and operative blood loss were similar between groups. Baseline hematological parameters for epoetin alfa vs PAD were not significantly different; however, by the day of surgery the epoetin alfa group had significantly higher hemoglobin (130 vs 114 g/L; P < .001), hematocrit (0.408 vs 0.352; P < .001), and reticulocyte count (3.4 vs 2.1 x 10(9) cells per liter; P < .001). These differences remained significant for 1 to 2 days postoperatively. There was no significant difference in the incidence of allogeneic transfusions between groups (28% for epoetin alfa vs 8% for PAD; P = .1383). Both treatments were generally well tolerated. Epoetin alfa appears to be a safe alternative to PAD in patients who are at risk for transfusion in the perioperative period following total knee arthroplasty.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Female; Hematinics; Humans; Male; Middle Aged; Preoperative Care; Prospective Studies; Recombinant Proteins; Treatment Outcome

Preoperative epoetin-alpha administration is said to have a limited effect in patients with chronic inflammatory diseases such as rheumatoid arthritis (RA), due to lower iron availability. We studied the effects of preoperative epoetin-alpha treatment in orthopedic surgery patients in a daily life setting in which iron supplementation was assured, and compared the effects in RA and non-RA patients.. In an open, naturalistic, randomized controlled trial, 695 orthopedic surgery patients with preoperative hemoglobin (Hb) values of 10-13 g/dL, either with RA (113) or without RA (582), received either preoperative epoetin-alpha treatment added to standard care, or standard care alone. Hb values and transfusions were evaluated from entry into the study until 4-6 weeks after surgery.. Both in RA and non-RA patients, perioperative Hb values were significantly higher and transfusion requirements were significantly lower in epoetin-alpha treated patients than in control patients (p < 0.001). In RA patients, the outcomes regarding Hb values were not significantly or relevantly different from non-RA patients.. Just as with orthopedic patients in general, RA patients benefit from preoperative epoetin-alpha treatment in combination with iron supplementation. We postulate that iron supplementation during epoetin-alpha therapy in RA patients is important for optimal efficacy.

Topics: Aged; Arthritis, Rheumatoid; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Epoetin Alfa; Erythropoietin; Female; Follow-Up Studies; Hemoglobins; Humans; Iron; Male; Middle Aged; Postoperative Complications; Premedication; Recombinant Proteins; Spinal Diseases; Treatment Outcome

Intravenous iron (FeIV) has been used increasingly, alone or in combination with recombinant erythropoietin, to promote red cell production as part of a blood conservation program. Given the important role that iron plays in the growth of bacteria, it has been hypothesized that this use of FeIV may promote surgical site infection. However, this hypothesis has not yet been tested appropriately. To assess this hypothesis, postoperative infection rates in patients undergoing cardiothoracic surgery were analyzed.. Data were collected on 863 patients undergoing cardiopulmonary bypass surgery in 2001. Patients were either enrolled voluntarily in a blood conservation program in which they received either postoperative FeIV and erythropoietin (n=302), as indicated, or blood transfusions and no FeIV (n=561), as indicated, to correct postoperative anemia. Infections were defined according to the U.S. Centers for Disease Control and Prevention guidelines.. Thirty-nine infections developed. The overall infection rate was 4.52%, with an infection rate of 3.97% in the iron-treated group (n=12) and a rate of 4.81% in the untreated group (n=27). When the impact of gender, age, diabetes mellitus, operating time, type of surgery, and blood transfusions were controlled for, FeIV did not increase the risk of infection (odds ratio of 1.031 for each increment of 125 mg of FeIV; 95% confidence interval 0.908, 1.170; p=0.64).. There was no impact of FeIV on the subsequent infection rate in a cardiac surgery patient cohort, indicating its safety for use in the postoperative setting.

Topics: Aged; Anemia; Bacterial Infections; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Drug Therapy, Combination; Erythropoietin; Female; Ferrous Compounds; Hematinics; Humans; Injections, Intravenous; Male; Prospective Studies; Recombinant Proteins; Surgical Wound Infection; Time Factors

In unilateral total knee replacement (TKR), perioperative blood loss, low transfusion thresholds and short hospital stay result in patients being discharged with low haemoglobin (Hb). We assessed the effects of perioperative administration of intravenous iron, with or without erythropoietin, plus a restrictive transfusion threshold (Hb < 80 g L(-1)) both on transfusion rate and recovery from post-operative anaemia. TRK patients received iron sucrose (2 x 200 mg per 48 h, iv) (Group IVI, n = 129). Patients with admission Hb < 130 g L(-1), also received erythropoietin (1 x 40 000 IU, sc) (Group EPO, n = 19). Perioperative clinical and laboratory data were obtained. Mean Hb loss was 36 g L(-1), but only seven patients were transfused (5%). Pre-operatively, 66 (45%) patients did not have enough stored iron to compensate Hb loss. At post-operative day 30, only 15% were anaemic, 70% of Hb loss and 92% of pre-operative Hb were recovered and ferritin increased by 73 microg L(-1) (P < 0.01), although erythropoietic response was higher in patients receiving erythropoietin (P < 0.05). No adverse effects of iron sucrose or erythropoietin were witnessed. This protocol seems to reduce allogeneic blood transfusion rate and may hasten the recovery from post-operative anaemia in TKR patients, without depleting iron stores. Further studies are needed to ascertain which patients may benefit of extended intravenous iron and/or erythropoietin administration.

Topics: Aged; Anemia; Arthroplasty, Replacement, Knee; Blood Component Transfusion; Blood Loss, Surgical; Erythropoietin; Female; Ferric Compounds; Ferric Oxide, Saccharated; Glucaric Acid; Hemoglobins; Humans; Male; Perioperative Care; Postoperative Hemorrhage; Receptors, Transferrin; Recombinant Proteins; Reticulocyte Count; Treatment Outcome

This study evaluated whether patients receiving a two-dose regime of epoetin alfa received less allogeneic blood than patients donating autologous blood before primary hip arthroplasty. Consenting patients with a hemoglobin level between 12 and 15 g/dL were randomly assigned to a two-dose administration of epoetin alfa (19 patients) or autologous donation (21 patients). Sixteen percent of the patients in the epoetin alfa group and 52% of the patients in the autologous donation group received transfusions, with a mean volume of 90 cc per patient in the epoetin alfa group and 340 cc in the autologous donation group. Hemoglobin was similar at screening; however, the epoetin alfa group achieved a higher hemoglobin (14.6 g/dL) than the autologous donation group (12.6 g/dL) before surgery. Hemoglobin remained significantly higher in the epoetin alfa group for 3 days after surgery. Administration of two doses of epoetin alfa provided patients with effective and safe reduction of allogeneic blood transfusions and decreased the necessity and difficulty of autologous donation before total hip arthroplasty.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Female; Hematinics; Humans; Male; Middle Aged; Recombinant Proteins

A limitation of preoperative autologous blood donation (PABD) in nonanemics and the use of recombinant human erythropoietin (EPO) in anemics (baseline hematocrit [Hct] < or = 39%) could be an efficient approach of the cost-benefit ratio of transfusion during primary total hip (THA) or knee (TKA) arthroplasties. We evaluated the consequences on transfusion rates and costs of two different applications of a transfusion policy based on personal requirements during primary THA or TKA. This quality assurance observational study compared two prospective successive time periods; each included successive patients treated by the same medical team and standardized care. In Study 1 (n = 182), PABD was indicated if there were insufficient estimated red blood cell reserve and a life expectancy > or = 10 yr, no use of EPO, and identical criteria for any transfusion. Because this policy led to a 50% allogeneic transfusion rate when baseline Hct < or = 37% and autologous blood wastage in the nonanemics (baseline Hct > 39%), 2 refinements were introduced in Study 2 (n = 708): EPO without PABD when baseline Hct < or = 37%, and life expectancy > or = 10 yr, and avoidance of PABD in nonanemics. This novel care induced a marked decrease in transfusion rates (respectively, from 41% to 7%, P < 0.0002, in nonanemics; from 58% to 27%, P < 0.003, in anemics; and from 43% to 12%, P < 0.0001, overall), with no change in allogeneic transfusion (10%) and discharge Hct, and a 39% financial savings. This saving effect is a result of the suppression of PABD in nonanemics, who represent 75% of this surgical population. Although erythropoietin is expensive, it can be used with cost savings in selected patients because the overall cost of transfusion is reduced.

Topics: Aged; Anemia; Anesthesia; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Donors; Blood Loss, Surgical; Blood Transfusion, Autologous; Costs and Cost Analysis; Erythrocyte Count; Erythropoietin; Female; Hematocrit; Humans; Length of Stay; Male; Organizational Policy; Prospective Studies; Recombinant Proteins

Preoperative anemia is a major risk factor for perioperative transfusion in orthopedic surgery and aging is associated with an increased risk for developing anemia. The aim of this study was to compare the efficacy and safety of preoperative epoetin alfa in patients older and younger than 65 years in orthopedic surgery. PATIENTS AHD METHOD: This study involved 75 patients scheduled for total joint arthroplasty who had an hemoglobin level between 100 and 130 g/l. Patients were assigned to receive weekly doses of subcutaneous epoetin alfa (40000 IU) on days -21, -14, -7, -1 before surgery. We tabulated age, weight, gender, baseline analytic parameters, perioperative evolution of the mean hemoglobin level, transfusion, side effects and complications.. Fifty-four patients were included in group A (> or = 65 years) and 21 in group B (< 65 years). The two study groups did not differ in terms of demographic characteristics and baseline analysis but differed in age and associated diseases. The preoperative increase in mean hemoglobin level (20 and 18 g/l) and transfusion rate (15% and 14.3%) were similar in both groups. There were no complications associated with the use of epoetin alfa.. Preoperative epoetin alfa administration seems to be as effective and safe in patients younger as in those older than 65 years.

Topics: Aged; Arthroplasty, Replacement; Blood Loss, Surgical; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Female; Hematinics; Humans; Male; Middle Aged; Recombinant Proteins

To investigate the effect of recombinant human erythropoietin (r-HuEPO) administration on perioperative hemoglobin concentrations and on the number of blood transfusions in patients undergoing surgery for gastrointestinal tract malignancies.. Erythropoietin has been shown to improve the yield of autologously predonated blood and to reduce the subsequent requirements for homologous blood transfusions in cancer patients.. In this double-blind placebo-controlled study, 31 cancer patients received subcutaneous r-HuEPO in a dose of 300 IU/kg body weight plus 100 mg iron intravenously (study group) and 32 patients received placebo medication and iron (control group). All patients received the medications daily for at least 7 days before and 7 days after the operation.. Patients who received erythropoietin received significantly fewer transfusions intraoperatively and postoperatively. Postoperatively, the study group had significantly higher hematocrit, hemoglobin, and reticulocyte count values compared to the control group. The use of erythropoietin was also associated with a reduced number of postoperative complications and improved 1-year survival.. Patients with gastrointestinal tract cancer and mild anemia benefit from perioperative erythropoietin administration in terms of stimulated erythropoiesis, reduction in the number of blood transfusions, and a favorable outcome.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Double-Blind Method; Erythropoietin; Female; Gastrointestinal Neoplasms; Hematocrit; Hemoglobins; Humans; Male; Multivariate Analysis; Postoperative Complications; Preoperative Care; Prospective Studies; Recombinant Proteins; Reticulocyte Count; Survival Rate

Preoperative autologous blood donation is one of the most widely used methods of autotransfusion. However securing a predetermined amount of blood (3 units of whole blood) may be difficult in patients with a low preoperative hematocrit. To determine the minimum effective pretreatment dosage of recombinant human erythropoietin required to secure an adequate amount of preoperative blood for autologous transfusion during posterior decompression and instrumentation fusion using the pedicle screw-rod system in the lumbar spine, a prospective randomized clinical trial was done. Forty-five patients who had a preoperative hematocrit less than 40% were selected and were divided blindly into three groups. Fifty units per kilogram of recombinant human erythropoietin seems to be the minimal effective dosage for securing an adequate amount of preoperative autologous blood donation.

Topics: Adult; Blood Loss, Surgical; Blood Transfusion, Autologous; Decompression, Surgical; Dose-Response Relationship, Drug; Double-Blind Method; Erythrocyte Volume; Erythropoietin; Female; Hematocrit; Humans; Male; Middle Aged; Plastic Surgery Procedures; Preoperative Care; Prospective Studies; Recombinant Proteins; Spine; Treatment Outcome

To evaluate the efficacy of perioperative recombinant human erythropoietin (r-HuEPO, epoetin alfa) in stimulating hematopoiesis and reducing allogeneic blood transfusion requirements in major head and neck cancer surgery.. Double-blinded, placebo-controlled, randomized, prospective clinical trial.. Fifty-eight patients undergoing surgical resection of head and neck tumors at the University of Iowa hospitals completed this study. Patients were required to have a pre-study hemoglobin >/=10.0 g/dL and

Topics: Adult; Aged; Aged, 80 and over; Anemia; Blood Loss, Surgical; Blood Transfusion; Double-Blind Method; Epoetin Alfa; Erythropoietin; Female; Head and Neck Neoplasms; Hematinics; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Recombinant Proteins

Serum erythropoietin (sEPO) level is known to increase as hemoglobin (Hb) concentration decreases during and after preoperative autologous blood donation (PAD). The endogenous erythropoietin (EPO) production after allogeneic blood transfusion has not to our knowledge, been studied. The aim of the present study was to determine whether there is, after surgery, any change in sEPO concentration after allogeneic blood transfusion, and whether there is any difference in EPO response after autologous or allogeneic blood transfusion. Thirty-one patients approaching total hip-joint replacement surgery, were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). The relationship between Hb, sEPO, and reticulocytes in the recipients were repeatedly analyzed before, during and after surgery. The Hb followed an expected pattern, with a decreased concentration after PAD in the autologous group, then in both groups after surgery. The sEPO concentration was significantly higher in the allogeneic than in the autologous group on day one and day 4-5 postoperatively. The reticulocyte level, on the contrary, was higher in the autologous patients before, one hour after, and one day after surgery. The study showed a greater increase in sEPO concentration after allogeneic blood transfusion than after autologous blood transfusion. There may be an inverse relationship between sEPO and the reticulocyte level.

Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Bone Cements; Erythropoietin; Female; Hemoglobins; Humans; Male; Middle Aged; Postoperative Period; Reticulocyte Count

A prospective, randomized trial comparing Epoetin alfa (Procrit) with placebo saline injection to determine effectiveness in increasing erythropoietic recovery in complex spine deformity surgery.. To determine if Epoetin alfa can allow preoperative autologous donation completion more effectively and reduce perioperative homologous blood transfusion.. The use of Epoetin alfa has been studied, primarily in the arthroplasty literature, for its effectiveness in decreasing transfusion requirements and increasing hemoglobin levels. It has not been studied in patients undergoing complex spine deformity surgery.. A total of 48 patients were prospectively randomized into an Epoetin alfa group and a control group. All patients attempted to donate 4 units of preoperative autologous donation at weekly intervals; 40,000 units of Epoetin alfa were injected subcutaneously at the time of preoperative autologous donation in the Epoetin alfa group. Hematocrit levels were recorded weekly during the donation process and daily in the preoperative period.. Preoperative autologous donation was completed more effectively in the patients receiving Epoetin alfa. Epoetin alfa resulted in statistically higher hematocrit levels during preoperative autologous donation and perioperatively (P < 0.005). Homologous transfusion was decreased by 2.4 units and hospital stay was 1.8 days shorter in patients receiving Epoetin alfa.. Patients who received Epoetin alfa were able to complete preoperative autologous donation more effectively, increase erythropoietic recovery, decrease homologous transfusion requirements, and had shorter hospital stays.

Topics: Adult; Aged; Blood Donors; Blood Loss, Surgical; Blood Transfusion, Autologous; Constipation; Contraindications; Epoetin Alfa; Erythropoietin; Female; Fever; Hematocrit; Humans; Injections, Subcutaneous; Length of Stay; Male; Middle Aged; Postoperative Complications; Postoperative Nausea and Vomiting; Preoperative Care; Prospective Studies; Recombinant Proteins; Sepsis; Spinal Curvatures; Spinal Fusion; Treatment Outcome

The vast majority of infants and children undergoing craniosynostosis correction receive a blood transfusion. The risks of blood transfusion include, but are not limited to, acute hemolytic reactions (approximately 1 of 250,000), human immunodeficiency virus (approximately 1 of 200,000), hepatitis B and C (approximately 1 of 30,000 each), and transfusion-related lung injuries (approximately 1 of 5000). This prospective, single-blinded, randomized study was undertaken to examine the safety and efficacy of preoperative single weekly dosing with erythropoietin (epoetin alfa) in reducing the rate of transfusion in infants and small children undergoing craniosynostosis repair. A total of 29 patients (<8 years) undergoing craniosynostosis repair were randomized into two groups: one received preoperative erythropoietin (600 U/kg) weekly for 3 weeks, and the other served as a control. All caregivers responsible for blood transfusions were blinded, and strict criteria for transfusion were established. A pediatric hematologist monitored both groups, and all patients received supplemental iron (4 mg/kg). Fourteen patients were randomized to receive erythropoietin, and eight of these 14 patients (57 percent) required transfusion (mean age, 17 months; mean weight, 10.1 kg). Of the six patients not requiring transfusion, three were younger than 12 months old (mean, 6 months). Fourteen of 15 patients (93 percent) in the control group (mean age, 13 months; mean weight, 9.3 kg) required a blood transfusion during the study. The only control patient not requiring transfusion was the eldest (5 years old). The difference between the two groups was statistically significant (Fisher's exact test = 0.03). The control group showed no change in hemoglobin levels from baseline to preoperative levels, but the erythropoietin group increased their average hemoglobin levels from 12.1 to 13.1 g/dl. There were no adverse effects noted among children receiving erythropoietin, nor were there any surgical complications. The authors conclude that the preoperative administration of erythropoietin significantly raised hemoglobin levels and reduced the need for a blood transfusion with craniosynostosis correction. More suggestions are made that may further reduce the need for blood transfusions, and a cost-benefit analysis is discussed.

Topics: Administration, Oral; Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Craniosynostoses; Erythropoietin; Hemoglobins; Humans; Infant; Iron; Preoperative Care; Prospective Studies; Recombinant Proteins; Single-Blind Method

Ketorolac, which may cause renal vasoconstriction by cyclooxygenase inhibition, is often administered to patients anesthetized with sevoflurane that is metabolized to inorganic fluoride (F(-)), another potential nephrotoxin. We assessed this possible interaction using urine N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine (U-NAG/crea) as a marker of proximal tubular, beta2-microglobulin as a tubular, urine oxygen tension (P(u)O(2)) as a medullary, and erythropoietin as a marker of tubulointerstitial damage. Thirty women (ASA physical status I-II) undergoing breast surgery were included in our double-blinded study. They were allocated into two groups receiving either ketorolac 30 mg IM (Group K) or saline (Group C) at the time of premedication, at the end of, and 6 h after anesthesia maintained with sevoflurane. Urine output, U-NAG/crea, P(u)O(2,) serum creatinine, urea, and F(-) were assessed. Blood loss was larger in Group K (465 +/- 286 mL vs 240 +/- 149 mL, mean +/- SD, P < 0.05). The MAC-doses of sevoflurane were similar. U-NAG/crea increased during the first 2 h of anesthesia and serum F(-) peaked 2 h after the anesthesia without differences between the groups. There were no statistically significant changes in P(u)O(2), erythropoietin, beta2-microglobulin, serum creatinine, urea, or urine output during anesthesia or the recovery period in either group. Our results indicate that the kidneys are not affected by ketorolac administered in connection with sevoflurane anesthesia.. The different kinetics of N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine and serum inorganic fluoride during and after sevoflurane anesthesia suggest that the observed mild renal tubular function deterioration is not caused by inorganic fluoride. Administration of ketorolac IM is therefore considered safe in adequately hydrated healthy adult patients given sevoflurane anesthesia.

Topics: Acetylglucosaminidase; Adult; Anesthetics, Inhalation; Anti-Inflammatory Agents, Non-Steroidal; Biomarkers; Blood Loss, Surgical; Breast; Creatinine; Double-Blind Method; Drug Interactions; Erythropoietin; Female; Fluorides; Humans; Ketorolac; Kidney Diseases; Methyl Ethers; Oxygen; Sevoflurane; Sodium

We assessed the feasibility and efficacy of subcutaneous erythropoietin alpha (EPO) therapy and preoperative autologous blood donation (ABD) in children undergoing open heart surgery. Thirty-nine children were treated consecutively with EPO (100 U x kg(-1) s.c. three times a week in the 3 weeks preceding the operation and i.v. on the day of surgery) and two ABDs were made (Group 1). As controls to compare transfusion requirements, 39 consecutive age-matched patients who had undergone open heart surgery during the two preceding years were selected (Group 2). In a mean time of 20 (SD 5) days, 96% of scheduled ABDs were performed and only three mild vasovagal reactions were observed. The mean volume of autologous red blood cells (RBC) collected was 6 (1) ml x kg(-1) and the mean volume of autologous RBC produced as a result of EPO therapy before surgery was 7 (3) ml x kg(-1), corresponding to a 28 (11)% increase in circulating RBC volume. The mean volume of autologous RBC collected was not different from that produced [6 (1) vs 7 (3) ml x kg(-1), P=0.4]. Allogenic blood was administered to three out of 39 children in Group 1 (7.7%) and to 24 out of 39 (61.5%) in Group 2. Treatment with subcutaneous EPO increases the amount of autologous blood that can be collected and minimizes allogenic blood exposure in children undergoing open heart surgery.

Topics: Adolescent; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiopulmonary Bypass; Child; Child, Preschool; Erythropoietin; Feasibility Studies; Female; Heart Defects, Congenital; Hemoglobins; Humans; Infant; Male; Platelet Count; Preoperative Care; Tissue and Organ Harvesting

All patients in the first group tolerated sampling of four transfusion units of autologous blood in the course of two weeks with subsequent erythropoietin administration very well. Erythropoietin was well tolerated, no local nor systemic undesirable side-effects or complications were observed. The mean transferrin and serum iron values remained during sampling of autotransfusions and erythropoietin administration within the range of normal values reported by our laboratory. The ferritin levels were above the norm. On the other hand in patients of the control group it was not possible--due to the decline of haemogram values--to sample in 45% the required amount of autologous blood before operation. For the same reason it was not possible to implement haemodilution as required. In similar blood losses administration of allogenic blood was necessary in 35% patients of the control group whereby in the group of patients with erythropoietin allogenic blood was administered in two cases (10%). Erythropoietin administration can effectively facilitate preoperative sampling of autotransfusion within a relatively short period. By its administration we can prevent a marked decline of red blood cells as a result of sampling of several preserves of autologous blood at a rapid rate. A satisfactory value of the haematocrit before the operation proper moreover makes it possible to collect a larger amount of blood in case of acute isovolaemic haemodilution. This enhances the patient's safety in relation to risks ensuing from administration of allogenic blood.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Carcinoma; Erythropoietin; Hematocrit; Hemodilution; Humans; Male; Preoperative Care; Prostatectomy; Prostatic Neoplasms

One hundred patients scheduled for elective colo-rectal cancer surgery, and with a preoperative haemoglobin level < or = 8.5 mmol/l were included. Eighty-one patients could be evaluated. Thirty-eight patients received r-HuEPO in a dose of 300 IU/kg body weight on day four before surgery and 150 IU/kg, daily, for the following seven days, and 43 patients received placebo. In addition, all patients received daily doses of 200 mg iron, orally, for four days before surgery. On the day of surgery and until discharge the haemoglobin concentration was significantly higher in the erythropoietin group compared to the placebo group. The number of blood transfusions given was significantly lower in the erythropoietin group with a mean of 0.3 units per patient (0-6) compared to 1.6 units (0-9) in the control group (p < 0.05). The clinical implications of these findings has yet to be assessed.

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Colonic Neoplasms; Double-Blind Method; Erythropoietin; Female; Hemoglobins; Humans; Intraoperative Care; Male; Middle Aged; Prospective Studies; Recombinant Proteins; Rectal Neoplasms; Transfusion Reaction

The safety and effects on hematocrit of recombinant human erythropoietin (epoetin alfa) were evaluated in men undergoing radical retropubic prostatectomy.. Between February 1, 1997 and November 2, 1998, 305 men with clinically localized adenocarcinoma of the prostate underwent radical retropubic prostatectomy performed by a single surgeon (H. L.). Of these men 283 with a baseline hematocrit of less than 48% received 600 IU/kg. epoetin alfa 14 days (-14) and 7 days (-7) before radical retropubic prostatectomy. Hematocrit was measured at baseline on day -14, on day -7, just before anesthesia induction on day 0, immediately postoperatively and on the day of discharge home. The number of allogeneic units transfused, and all intraoperative and postoperative complications were recorded.. Mean hematocrit at baseline on day -14 and at induction on day 0 was 42.9% and 45.8%, respectively (p = 0.0001). The frequency of hematocrit decreasing, showing no change or increasing 0.1 to 1.9, 2.0 to 3.9 or greater than 4.0 hematocrit points was 16.5%, 0.5%, 23%, 22% and 38%, respectively. Of the men 17% had no increase in hematocrit. A weak correlation existed between baseline hematocrit and the erythropoietic response to epoetin alfa (r2 = 0.06). Mean change in hematocrit after treatment with epoetin alfa in the quartile baseline hematocrit groups 34.2 to 41.4, 41.5 to 43.2, 43.3 to 44.9 and 45.0 to 48.0 hematocrit points was 3.71, 2.45, 3.86 and 1.02 hematocrit points, respectively. Of the surgical candidates 22 (9.1%) achieved an induction hematocrit of greater than 51%. Of the 283 men receiving epoetin alfa 21 (7.4%) also received an allogeneic transfusion. The transfusion rate did not correlate with induction hematocrit. The only adverse cardiovascular event was an uncomplicated postoperative pulmonary embolus.. Our prospective study demonstrates that epoetin alfa given preoperatively in 2 doses of 600 IU/kg. is safe for significantly increasing hematocrit in men before radical retropubic prostatectomy. It is intuitive that the significant increase in hematocrit decreases the requirement for allogeneic blood transfusion.

Topics: Adenocarcinoma; Blood Loss, Surgical; Epoetin Alfa; Erythropoietin; Hematinics; Hematocrit; Humans; Male; Middle Aged; Preoperative Care; Prospective Studies; Prostatectomy; Prostatic Neoplasms; Recombinant Proteins

To compare two modalities of iron supplementation for the preoperative stimulation of erythropoiesis using recombinant human erythropoietin (rhEPO), 12 adults in normal hemoglobin and iron status due for elective surgery were randomized to rhEPO 200 U/kg body weight subcutaneously twice weekly combined with either iron sucrose 200 mg intravenously twice weekly or iron sulfate 160 mg/day orally, for 3 weeks preoperatively. Efficacy was measured by the increases over baseline in hemoglobin, reticulocyte count, and ferritin determined 3 days before surgery; preoperative reticulocyte count and ferritin were significantly higher with intravenous iron, whereas the only significant intragroup increases in hemoglobin between time points also occurred in this group. Intravenous iron significantly boosts the hematopoietic response to rhEPO and prevents iatrogenic iron depletion in otherwise healthy candidates for elective surgery.

Topics: Administration, Oral; Adult; Blood Loss, Surgical; Erythropoietin; Ferritins; Hemoglobins; Humans; Injections, Intravenous; Iron; Perioperative Care; Prospective Studies; Recombinant Proteins; Reticulocyte Count

This study evaluates the real effectiveness of epoetin-alpha associated with ferrous sulphate, in reducing blood transfusion in patients undergoing elective open heart surgery not treated with autologous donation.. Sixty patients had been divided into 2 groups: group A (30 patients) treated with 525 mg ferrous sulphate three time a day per os for 3 weeks; group B (30 patients) treated with epoetin-alpha 10,000 UI twice a week and 525 mg ferrous sulphate 3 times a day. Grouping of patients has been randomized. In both groups hemoglobin, hematocrit, reticulocytes, iron values, ferritine, transferrine, and serological values, have been evaluated sequentially before treatment, before surgery, day of operation, 1st, 2nd, 3rd, 7th postoperative days and at discharge.. In group A 86% patients needed blood transfusion (26 out of 30); in group B only 3% of patients needed blood transfusion (1 patient). One year follow up didn't show side effects related to epoetin-alpha.. This study confirms the real effectiveness of epoetin-alpha in reducing the postoperative need for homologous blood transfusion. No side effects due to epoetin-alpha treatment have been proved. The conclusion is drawn that epoetin-alpha can be used as an alternative to blood transfusion or in association with predeposit and in the treatment of basal anemia.

Topics: Blood Loss, Surgical; Coronary Disease; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Female; Ferrous Compounds; Heart Valve Diseases; Hematinics; Humans; Male; Middle Aged; Recombinant Proteins

In a double-blind placebo-controlled study we investigated the effect of recombinant human erythropoietin (r-HuEPO), on the perioperative hemoglobin concentration and the use of blood transfusions in patients undergoing elective colorectal surgery with a preoperative hemoglobin level

Topics: Adult; Aged; Aged, 80 and over; Blood Loss, Surgical; Blood Transfusion; Chi-Square Distribution; Colorectal Neoplasms; Double-Blind Method; Erythropoietin; Female; Hemoglobins; Humans; Intraoperative Period; Male; Middle Aged; Postoperative Period; Prospective Studies; Recombinant Proteins; Statistics, Nonparametric

A multicenter, randomized, open-label, parallel-group study was conducted to compare the safety and efficacy of perioperative recombinant human erythropoietin (Epoetin alfa) with the safety and efficacy of preoperative autologous donation (PAD) in total joint arthroplasty. A total of 490 patients scheduled for total joint (i.e., hip or knee) surgery and having hemoglobin (Hb) levels > or = 11 to < or = 13 g/dL were randomized to receive weekly doses of subcutaneous Epoetin alfa on preoperative Days -21, -14, and -7, and on the day of surgery, or to participate in a PAD program. The mean baseline Hb level in both groups was 12.3+/-0.6 g/dL, increasing to 13.8 g/dL in the Epoetin alfa-treated group and decreasing to 11.1 g/dL in the PAD group before or on the day of surgery. In the PAD group, 156/219 (71.2%) patients were transfused with autologous blood, and 42/219 (19.2%) patients were transfused with allogeneic blood. A smaller proportion, 27/209 (12.9%) patients, in the Epoetin alfa-treated group were transfused with allogeneic blood (P = .078 compared with the PAD group). Moreover, patients in the PAD group received a total of 325 units of blood (79 allogeneic units and 246 autologous units) compared with patients in the Epoetin alfa group who received a total of 54 units of blood. The mean postoperative Hb level was 11.0 g/dL in the Epoetin alfa-treated group and 9.2 g/dL in the PAD group. Compared with the PAD arm, mean Hb levels measured preoperatively, postoperatively on Day 1, and at discharge visits were significantly greater in the Epoetin alfa-treated arm (P < .0001 ).

Topics: Age Factors; Anemia; Arthroplasty, Replacement; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Hematinics; Hemoglobins; Humans; Postoperative Complications; Prospective Studies; Recombinant Proteins; Sex Factors

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.

Topics: Adult; Blood Coagulation; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Female; Fibrinolysis; Hip Joint; Humans; Male; Middle Aged; Platelet Count; Recombinant Proteins

Acute normovolaemic haemodilution (ANH) is used to avoid perioperative blood loss and consists of the withdrawal of whole blood just before or just after anaesthesia induction and its simultaneous replacement by synthetic colloids and crystalloid solutions. In an attempt to improve the efficiency of this technique while at the same time avoiding cardiovascular complications, we set up a pilot study to test the association of rHuEpo/ANH during elective surgery for total hip replacement. Five patients (3 males, 2 females) were included in this study. The amount of whole blood drawn was 3 x 450 ml from the men and 2 x 450 ml from the women. Before blood was taken, the mean increase in haemoglobin was 1.2 +/- 0.9 g/dl and mean increase in reticulocytes 106 +/- 34 G/l. No patient received homologous transfusion during the perioperative period; 3 patients received the totality of predonated blood and one patient 2 of the 3 units taken. The mean fall in haemoglobin at day 1 post-surgery was 3.6 g/dl. In conclusion, the stimulation of erythropoiesis by rHuEpo in the pre-surgery phase led on average to a 1 g/dl gain in haemoglobin, permitting an isovolaemic withdrawal of 900 to 1350 ml of blood depending on body weight without the development of severe anaemia. It was thus possible to perform total hip replacement in all the patients without homologous blood support and with a post-surgery haemoglobin value of > 10 g/dl. This protocol should be further tested in a prospective randomised study (rHuEpo versus placebo) in order to assess the real benefit of rHuEpo.

Topics: Adult; Aged; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Hemodilution; Hemoglobinometry; Humans; Male; Middle Aged; Pilot Projects; Postoperative Complications; Recombinant Proteins; Treatment Outcome

A randomised, placebo-controlled trial was conducted to study whether the subcutaneous administration of recombinant human erythropoietin (rhEPO) increases the donated red cell blood volume in patients with rectal cancer. Patients with resectable rectal cancer and a haemoglobin (Hb) level > or = 12.5/ > 12 g/dl (males/females) were scheduled to receive pre-operatively either erythropoietin (200 U/kg body weight daily) (n = 28) or placebo (n = 26) subcutaneously for 11 days. During this period autologous blood was collected. No serious adverse events were attributed to erythropoietin. 20 of 28 patients treated with rhEPO were able to donate > or = 3 units (71%) compared with 11 of 26 control patients (42%). The mean cumulative volume of red cells donated was 29% higher in the patients who received rhEPO (571 versus 444 ml, P = 0.02). The change in the mean reticulocyte value from baseline to the last pre-operative value was significantly higher in the rhEPO group (10.4 to 61.6/1000 versus 11.0 to 20.1/1000, P = 0.0001). The fall in the mean haematocrit from baseline to the last pre-operative value was significantly lower in the rhEPO group (41.4 to 37.6% versus 41.8 to 34.8%, P = 0.0004). rhEPO increases the ability of cancer patients to donate autologous blood during a short pre-operative period and enhances the restoration of haematological values after the donation period.

Topics: Adult; Aged; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion, Autologous; Double-Blind Method; Erythropoietin; Female; Hemoglobins; Humans; Male; Middle Aged; Recombinant Proteins; Rectal Neoplasms; Transferrin

In a double-blind, randomized, placebo-controlled trial, we evaluated the ability of epoetin beta (recombinant human erythropoietin) to avoid allogeneic blood transfusions (ABT) and the associated risks in patients undergoing primary elective open-heart surgery and in whom autologous blood donation (ABD) was contraindicated. Seventy-six patients overall were enrolled onto the trial and were randomly assigned to the two treatment groups, 5 x 500 U/kg body weight (BW) epoetin beta or placebo intravenously over 14 days preoperatively. All patients received 300 mg Fe2+ orally per day during the treatment period. Preoperatively, the mean hemoglobin increase was 1.50 g/dL greater in epoetin beta patients than in placebo patients (95% confidence interval, 1.10 to 1.90 g/dL), allowing a rapid return to the baseline value by the seventh postoperative day in most epoetin beta patients. The mean volume of blood collected by intraoperative isovolemic hemodilution was 562 mL (red blood cell mass, 274 mL) in the epoetin beta group and 218 mL (red blood cell mass, 94 mL) in the placebo group, respectively. Only four patients (11%) in the epoetin beta group received an ABT, compared with 19 (53%) in the placebo group (P = .0003). Epoetin beta was most useful in patients with a perioperative blood loss greater than 750 mL, in those with a baseline hematocrit value less than 0.42, and in those aged > or = 60 years. The iron supplementation proved adequate despite the fact that a significant decrease in ferritin (median, 48.1%) and transferrin saturation (median, 40.5%) was observed in epoetin beta patients preoperatively. No influence of epoetin beta therapy on blood pressure, laboratory safety variables, or the frequency of specific adverse events was observed. Intravenous epoetin beta treatment of 5 x 500 U/kg BW in combination with 300 mg Fe2+ orally per day administered over 14 days preoperatively is an adequate therapy for increasing mean hemoglobin levels by approximately 1.50 g/dL and reducing the allogeneic blood requirement in patients undergoing elective open-heart surgery and in whom ABD is contraindicated.

Topics: Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Erythropoietin; Female; Humans; Injections, Intravenous; Male; Middle Aged; Recombinant Proteins

To avoid the inherent risk of complications associated with perioperative allogeneic transfusion, preoperative autologous blood donation (PAD) is frequently employed by patients undergoing major elective surgical procedures. However, many patients are unable to donate a sufficient quantity of blood prior to surgery. Recent studies have shown that epoetin alfa (Procrit; Ortho-Biotech, Raritan, NJ) effectively increases red blood cell (RBC) mass when administered preoperatively and decreases the requirement for allogeneic transfusion. These studies also demonstrated that patients with baseline hemoglobin levels ranging from 10 to 13 g/dL have the highest risk for requiring allogeneic transfusions and appear to achieve the greatest benefit from epoetin alfa treatment. We evaluated several dosing regimens and schedules for perioperative epoetin alfa administration. In our initial study, the comparative efficacy of three different epoetin alfa regimens was assessed by hemoglobin concentration, hematocrit, and absolute reticulocyte counts. In addition, we analyzed the effect of accelerated erythropoiesis on iron indices and individual RBC hemoglobin content. Our study demonstrated that epoetin alfa is safe and effective in increasing RBC mass; however, iron stores considered sufficient for basal erythropoiesis may not optimally support the accelerated RBC production associated with epoetin alfa therapy. In a subsequent randomized multicenter trial, we compared weekly epoetin alfa dosing to daily dosing in patients undergoing elective major orthopedic surgery. The results of this study indicated that administering epoetin alfa on a weekly schedule for several weeks prior to surgery may be at least as effective and more convenient than perioperative daily epoetin alfa dosing.

Topics: Blood Loss, Surgical; Blood Transfusion; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Randomized Controlled Trials as Topic; Recombinant Proteins; Transfusion Reaction; Transplantation, Autologous; Transplantation, Homologous

In an effort to avoid allogeneic transfusions, many patients scheduled for radical retropubic prostatectomy (RRP) participate in preoperative autologous donation (PAD) programs. Yet, PAD programs are costly, time-consuming, and not without risks. Perioperative administration of recombinant human erythropoietin (Epoetin alfa) also has been shown to reduce patients exposure to allogeneic transfusion. This study sought to compare the costs and transfusion rates associated with either PAD or perioperative Epoetin alfa in patients undergoing RRP.. The study population consisted of 120 men randomized to one of two treatment groups. Patients in group 1 donated up to 3 U of autologous blood preoperatively, provided that their hematocrit (HCT) was 33% or higher. Patients in group 2 received 600 IU/kg of Epoetin alfa on days -14 and -7 preoperatively, provided that their HCT was 46% or lower.. Overall, 107 (89%) of 120 patients underwent RRP. In group 1, 5 (9.6%) of 52 patients received a total of 12 U of allogeneic blood (0.23 U/patient). In group 2, 5 (9.6%) of 52 patients received a total of 10 U of allogeneic blood (0.19 U/patient). Three patients in group 1 but no patients in group 2 experienced an adverse event. The average costs related to PAD and pharmacologic administration per patient were $540 in group 1 and $657 in group 2. Participation in PAD required an average of 5 hours more per patient compared with Epoetin alfa administration.. Preoperative Epoetin alfa therapy is safe, well tolerated, and equally effective as PAD in reducing allogeneic blood transfusion requirements. Epoetin alfa therapy also is comparable in cost to PAD and offers patients greater convenience and less of a time commitment.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion, Autologous; Costs and Cost Analysis; Erythropoietin; Hematocrit; Humans; Male; Middle Aged; Preoperative Care; Prostatectomy; Recombinant Proteins

In previous studies, treatment with epoetin alfa facilitated preoperative donation of autologous blood (AB). However, some patients may not be able to donate sufficient AB to meet their surgical blood requirements when the time to surgery is short. In this multicenter, double-blind, placebo-controlled study, the ability of epoetin alfa combined with normovolemic hemodilution (NVHD) to facilitate the collection of > or = 4 AB units within 2 weeks of surgery was investigated in 112 nonanemic patients scheduled for elective orthopedic or vascular surgery. All patients received oral iron supplementation and were treated with three intravenous (i.v.) injections of epoetin alfa (300 or 600 IU/kg) on days 1,4, and 7; surgery, in combination with NVHD, was performed on day 13. A total of 4 units of AB were predeposited if the patient's hemoglobin (Hb) level exceeded 11 g/dL at each donation. Compared with placebo, epoetin alfa dose-dependently increased reticulocyte counts prior to surgery and significantly minimized the decrease in hematocrit (Hct) associated with AB donation, although there were no significant differences between dosages. While significantly more patients treated with epoetin alfa were able to donate > or = 4 AB units compared with placebo, there was no difference between the groups in exposure to allogeneic blood. This effect of epoetin alfa was particularly apparent in female patients. I.v. epoetin alfa 300 IU/kg, administered three times within 1 week, appears to be the optimum dose for facilitating the collection of > or = 4 units of AB in nonanemic patients scheduled for elective surgery and NVHD within 2 weeks.

Topics: Administration, Oral; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Dose-Response Relationship, Drug; Double-Blind Method; Epoetin Alfa; Erythropoiesis; Erythropoietin; Female; Hemodilution; Humans; Iron; Male; Orthopedics; Premedication; Recombinant Proteins; Reticulocyte Count; Time Factors; Treatment Outcome; Vascular Surgical Procedures

A multicenter, double-blind, placebo-controlled, parallel-group study was undertaken to determine whether Epoetin alfa can reduce perioperative transfusion requirements. Twenty-six medical centers enrolled 316 patients who were scheduled for major orthopedic surgery and were expected to require > or = 2 units of blood. Patients were stratified according to baseline hemoglobin levels and randomly assigned to receive either Epoetin alfa (300 IU/kg or 100 IU/kg) or placebo for 15 consecutive days starting 10 days prior to, on the day of, and for 4 days after surgery. Epoetin alfa (300 IU/kg) resulted in significantly less exposure to allogeneic blood transfusion compared with placebo (16%) versus 45%) in patients whose baseline hemoglobin level was > 10 to < or = 13 g/dL (P = 0.024). Mean number of units transfused per patient was also lower among those treated with Epoetin alfa (overall, P = 0.027). Epoetin alfa was safe and well tolerated in this population.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Double-Blind Method; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hematocrit; Hemoglobinometry; Hip; Humans; Intraoperative Period; Knee; Male; Middle Aged; Orthopedics; Postoperative Complications; Preoperative Care; Recombinant Proteins; Risk Factors; Thrombosis

Previous studies have demonstrated the efficacy of perioperative Epoetin alfa in decreasing allogeneic transfusion exposure in patients undergoing orthopedic surgery. A randomized, multicenter trial was conducted comparing the safety and efficacy of a weekly Epoetin alfa dosing regimen in patients with hemoglobin levels > or = 10 to < or = 13 g/dL scheduled to undergo major elective orthopedic arthroplasty, with a daily regimen previously shown to be effective. patients on the weekly regimen showed a greater baseline-to-presurgery hemoglobin increase versus the daily regimen group (1.44 +/- 1.029 g/dL versus 0.73 +/- 0.867 g/dL). Moreover, the weekly 600 IU/kg regimen was similar to the daily 300 IU/kg regimen with respect to safety and the avoidance of allogeneic transfusion. These data showed the weekly Epoetin alfa regimen to be at least as efficacious as the daily regimen and more convenient.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Drug Administration Schedule; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hemoglobinometry; Humans; Intraoperative Period; Male; Middle Aged; Orthopedics; Preoperative Care; Recombinant Proteins

Topics: Adolescent; Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Christianity; Dose-Response Relationship, Drug; Double-Blind Method; Erythropoietin; Female; Hip Prosthesis; Humans; Male; Middle Aged; Recombinant Proteins; Risk Factors

A double-blind, randomized and placebo-controlled study was performed with 62 patients undergoing orthopedic hip surgery. Mean hemoglobin levels at surgery, after four weekly blood-donations were 12.3, 12.7 and 13.9 g/dL for the patients receiving placebo, 100 and 200 IU/kg r-hu EPO respectively, via the subcutaneous route. The groups receiving r-hu EPO were operated on without any homologous blood supply. The endogenous erythropoietin levels remained stable throughout the observation period in the treatment groups, whereas they increased in the placebo group. The study confirms the known efficacy of erythropoietin in preoperative autologous blood-donation, but the ideal dose for each individual patient remains to be defined.

Topics: Aged; Aged, 80 and over; Blood Component Removal; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Female; Hip Prosthesis; Humans; Male; Middle Aged; Preoperative Care; Surgical Procedures, Operative

Concern about the risk of transmission of viral infection has led to attempts to reduce transfusion requirements in patients undergoing surgery. To determine whether recombinant human erythropoietin decreases blood transfusion requirements in patients undergoing elective hip arthroplasty, a multicentre double-blind, randomised, placebo-controlled trial was conducted. 208 patients undergoing elective primary or revision hip arthroplasty were randomised to 3 groups. All received daily subcutaneous injections of either erythropoietin or placebo starting 10 days before surgery. Group 1 (78 patients) received 14 days of placebo, group 2 (77 patients) received 14 days of erythropoietin (300 units/kg to a maximum of 30,000 units), and group 3 (53 patients) received placebo for days 10 to 6 before surgery and erythropoietin for the next 9 days. A primary outcome event (any transfusion or a haemoglobin concentration < 80 g/L) occurred in 46% of patients in group 1, 23% in group 2, and 32% in group 3 (p = 0.003). The mean number of transfusions was 1.14 in group 1, 0.52 in group 2, 0.70 in group 3. The mean reticulocyte count the day before surgery was 72 x 10(9)/L in group 1, 327 in group 2, and 170 in group 3. Deep venous thrombi were detected in 5 patients in group 1, 8 patients in group 2, and 8 patients in group 3. Patients who had a haemoglobin concentration before randomisation of < 135 g/L benefited most from erythropoietin. Thus erythropoietin given for 14 days perioperatively decreases the need for transfusion in patients undergoing elective hip arthroplasty.

Topics: Aged; Blood Cell Count; Blood Loss, Surgical; Blood Pressure; Blood Transfusion; Double-Blind Method; Drug Administration Schedule; Erythropoietin; Female; Ferritins; Follow-Up Studies; Hemoglobins; Hip Prosthesis; Humans; Injections, Subcutaneous; Iron; Male; Middle Aged; Postoperative Complications; Recombinant Proteins; Thrombophlebitis; Treatment Outcome

The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS).. From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused.. The average follow-up duration was 38.13 months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011).. Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.

Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Case-Control Studies; Erythropoietin; Humans; Postoperative Complications; Spinal Neoplasms

Research on preoperative blood management in older patients with delayed surgery for intertrochanteric fracture is scarce, especially regarding hematopoiesis and hemostasis. We assessed the effectiveness of optimized blood management programs in older patients undergoing delayed surgery for intertrochanteric fractures.. This retrospective study included 456 patients who underwent delayed surgery for intertrochanteric fractures. According to the optimized blood management plan, the patients were divided into four groups: group A was the control group; group B received 1 g of tranexamic acid (TXA) intravenously at admission; group C underwent sequential TXA treatment after admission until 1 day before surgery (1 g/day); and group D received iron supplements (200 mg/day) in addition to the treatment administered to group C, with or without recombinant human erythropoietin (rHuEPO; 40,000 IU). The primary outcomes were preoperative hidden blood loss (HBL), preoperative allogeneic blood transfusion (ABT) rate, hemoglobin (Hb) change, and actual Hb drop.. The Hb reduction, calculated HBL, and hospitalization duration in groups C and D were significantly lower than those in groups A and B. The preoperative ABT rates in groups C and D were significantly lower than those in groups A and B, with no significant difference between groups C and D.. The results of this study suggested that iron supplementation (with or without rHuEPO) combined with the sequential IV TXA scheme did not show a better clinical effect than the sequential IV TXA scheme in the management of patients undergoing delayed surgery for intertrochanteric fractures. Therefore, further evaluation is needed before recommending iron supplements and rHuEPO in older patients.

Topics: Aged; Blood Loss, Surgical; Erythropoietin; Hip Fractures; Humans; Iron; Retrospective Studies; Tranexamic Acid

Assess the effect of a protocol of preoperative erythropoietin (EPO) and ferrous sulfate in addition to perioperative tranexamic acid (TXA) on blood transfusions in patients with coronal or metopic craniosynostosis undergoing cranial vault remodeling (CVR) with fronto-orbital advancement (FOA).. Retrospective review of all coronal and metopic craniosynostosis patients undergoing CVR and FOA from March 2010 to June 2019 was performed. Before 2014 ("Control group"), all patients received blood transfusion at the start of surgery. In 2014, a protocol of preoperative EPO and ferrous sulfate with perioperative TXA and non-automatic transfusion was instituted ("Study group"). Patient demographics and anthropometrics, perioperative hemoglobin (Hb) levels, and transfusion details were collected and compared.. Thirty-six patients met inclusion criteria. Twenty-one patients were in the control group, and 15 in the Study group. Nineteen patients had metopic synostosis, 11 had unicoronal synostosis, and 6 had bicoronal synostosis. There were no significant differences between groups in demographics, operative time, intraoperative crystalloid volume, craniofacial syndromes, or sutures affected. The Study group had higher preoperative Hb (13.9 ± 1.0 vs. 12.6 ± 0.8 g/dL, p < 0.001), lower intraoperative Hb nadir (7.4 ± 1.8 vs. 9.2 ± 1.2 g/dL) lower intraoperative transfusion rate (66.7% vs. 100%, p = 0.008), lower postoperative transfusion rate (0% vs 28.6%, p = 0.03), and exposure to fewer unique units of packed red blood cells (0.7 ± 0.6 vs. 1.5 ± 0.9 units).. Our protocol resulted in decreased transfusion needs. These results add valuable information to the growing body of work on transfusion reduction in craniosynostosis surgery.

Topics: Blood Loss, Surgical; Blood Transfusion; Craniosynostoses; Erythropoietin; Humans; Infant; Retrospective Studies; Tranexamic Acid

Approximately one in 2000 babies are born with craniosynostosis, and primary open repair is typically performed before 1 year of age. Historically, the procedure has been associated with nearly 100 percent transfusion rates. To decrease the rates of transfusion, the authors' center has developed a novel multimodal blood conservation protocol.. The authors administered their standard of care to children aged 1 year or younger undergoing primary repair of craniosynostosis between 2008 and 2014. In 2014, the authors implemented the following protocol: (1) preoperative erythropoietin and ferrous sulfate, (2) local anesthetic with epinephrine infiltration of the incision, (3) PlasmaBlade incision and subgaleal dissection, (4) hypervolemic hemodilution, and (5) intravenous tranexamic acid. Procedures performed before the protocol implementation served as controls. The authors performed classic fronto-orbital advancement with anterior cranial vault remodeling for coronal and metopic craniosynostosis. For lambdoid and sagittal craniosynostosis, barrel stave osteotomies, cranial base outfracture, and interposition bone grafting were performed.. A total of 279 children with a mean age of 6 months who had craniosynostosis repairs were included. One hundred forty-five underwent repair before the authors' protocol, and 134 had repairs during the authors' blood conservation protocol. Both groups were similar in demographics. Overall blood loss and operative times were significantly reduced by 73 percent and 11 percent, respectively. Blood transfusion rate decreased 92 percent (p < 0.001).. These results show a strong association between the authors' blood conservation protocol and significantly reduced transfusion rates. The authors believe this is a significant step forward and can be safely applied in the great majority of children undergoing craniosynostosis repairs.. Therapeutic, III.

Topics: Blood Loss, Surgical; Craniosynostoses; Dissection; Epinephrine; Erythropoietin; Female; Ferrous Compounds; Hemodilution; Humans; Infant; Infant, Newborn; Male; Osteotomy; Plastic Surgery Procedures; Vasoconstrictor Agents

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.. The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.. Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.. A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Bloodless Medical and Surgical Procedures; Carcinoma, Pancreatic Ductal; Erythropoietin; Feasibility Studies; Female; Hemoglobins; Humans; Jehovah's Witnesses; Length of Stay; Male; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Perioperative Care; Postoperative Complications; Splenectomy; Treatment Outcome; Treatment Refusal

Patient blood management in orthopaedic surgery reduces transfusion risk. The best protocol is unknown. The effectiveness of a protocol based on the Seville Consensus on the reduction of transfusion risk is evaluated and a predictive transfusion equation is proposed in knee surgery.. Cohort study in patients undergoing knee and hip arthroplasty from January 2014 to December 2015 at a second level complexity hospital in Vilafranca del Penedès (Barcelona). Patients with Hb between 10 and 13g/dL were classified as anaemic with or without iron deficiency and received iron or combination of iron and erythropoietin. On the day of surgery, tranexamic acid was administered, the Hb drop was measured the next day and the requirements and the transfusion lintel were measured during the stay.. A total of 334 patients were included in the study. The implementation of the programme decreased the transfusion risk from 41.5% to 14.8% at the end of the study. In hip surgery, transfused patients were significantly older, sicker and with lower preoperative Hb. Tranexamic acid did not decrease bleeding. In knee surgery, the administration of tranexamic acid was the variable that most decreased the transfusion risk followed by a high preoperative Hb. The equation predicts transfusion risk with a sensitivity of 55% and specificity of 95.7%.. The implementation of the programme reduces transfusion risk. The effectiveness of tranexamic acid varies according to surgery site. The use of iron and recombinant human erythropoietin is necessary to improve Hb.

Topics: Aged; Aged, 80 and over; Anemia; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Erythrocyte Transfusion; Erythropoietin; Female; Hemoglobins; Humans; Iron Compounds; Male; Postoperative Hemorrhage; Premedication; Preoperative Care; Procedures and Techniques Utilization; Spain; Tranexamic Acid

Topics: Aged; Anemia; Blood Loss, Surgical; Erythropoietin; Female; Humans; Iron; Jehovah's Witnesses; Male; Middle Aged; Preoperative Care

To assess the success of a protocol using preoperative erythropoietin (EPO) and iron with perioperative tranexamic acid (TXA) in reducing blood transfusion in sagittal craniosynostosis surgery.. A retrospective chart review of all sagittal craniosynostosis patients undergoing open repair at our institution since 2010 was conducted. A novel protocol of preoperative EPO with iron and perioperative TXA, along with a shift away from automatic transfusion, was initiated in 2014. Perioperative hemoglobin levels, length of stay, and transfusion rates were compared between the historical control and the study group receiving the protocol.. A total of 36 patients met inclusion criteria. Twenty-eight patients were male and 8 were female. Twenty-two patients were in the control group receiving neither TXA nor EPO and automatically received a transfusion, while 14 were in the study group and received the full protocol. There were no significant demographic differences between groups. Within the control group, 100% of patients were transfused compared with 14.3% of the study group (p < 0.0001). The study group also had a shorter postoperative length of stay in the hospital (mean, 3.4 days; range, 3-6) than the control (mean, 4 days; range, 2-5.5, p = 0.038). The study group had a higher preoperative hemoglobin than the control (13.6 vs. 11.8 g/dL, p = 0.0001).. Our protocol of preoperative EPO and iron with perioperative TXA increased the preoperative hemoglobin and was associated with a low transfusion rate without negatively impacting postoperative course.

Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Blood Transfusion; Child; Clinical Protocols; Craniosynostoses; Erythropoietin; Female; Hemoglobins; Hospitals, Pediatric; Humans; Iron; Male; Minnesota; Plastic Surgery Procedures; Retrospective Studies; Tranexamic Acid

Little has been published on blood management in total hip and knee arthroplasty (THA and TKA, respectively) patients focusing on both hematopoiesis and hemostasis. Our aim was to explore the effectiveness and safety of an optimized blood management program in THA and TKA patients in a large, single-center, retrospective study.We retrospectively reviewed consecutive primary unilateral THA and TKA patients' data at our institution through the National Health Database. They were divided into 3 groups according to an optimized blood management program: group A-combined use of intravenous and topical tranexamic acid (TXA); group B-use of recombinant human erythropoietin (rHuEPO) and iron supplements in addition to treatments in group A; group C-use of additional multiple boluses of TXA in addition to treatments in group B. The primary outcomes were hemoglobin (Hb) drop and calculated total blood loss (TBL). Other outcome measurements such as transfusion rate, postoperative length of stay (PLOS), venous thromboembolism (VTE), and mortality were also compared.From 2014 to 2016, a total of 1907 unilateral THA (986 in group A, 745 in group B, and 176 in group C) and 1505 unilateral TKA (795 in group A, 556 in group B, and 154 in group C) procedures were conducted at our institution. The Hb drop, calculated TBL, and PLOS in group C were significantly lower than those in groups A and B for THA and TKA patients. The transfusion rate in group C was also significantly less than in groups A and B for THA patients, while it was similar in groups A and B for TKA patients. No patients in group C received a transfusion. A significant difference was not detected in the incidence of deep vein thrombosis. No episode of symptomatic pulmonary embolism or all-cause mortality occurred within 30 days postoperatively.The current retrospective study suggests that for patients receiving primary unilateral THA or TKA, multiple boluses of intravenous TXA combined with topical TXA, rHuEPO, and iron supplements can reduce the calculated TBL, Hb drop, transfusion rate, and PLOS without increasing the incidence of VTE or mortality.

Topics: Administration, Intravenous; Administration, Topical; Adult; Aged; Anemia; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Erythropoietin; Female; Humans; Iron; Male; Middle Aged; Recombinant Proteins; Retrospective Studies; Trace Elements; Tranexamic Acid

Erythropoietin (EPO) is proposed preoperatively to reduce blood transfusion in anemic patients (hemoglobin < 13 g/dL) scheduled for a major orthopedic surgery. New intravenous iron formulations allow infusion of higher doses, increasing EPO response. In that context, we evaluated in a before-after study (n = 62 and 65 patients for each period) a new EPO administration protocol (2 injections 4 and 3 weeks before surgery, and a third if hemoglobin <13 g/dL instead of <15 g/dL 2 weeks before surgery). After this protocol implementation, the mean (standard deviation) number of EPO injections decreased from 2.8 (0.5) to 2.2 (0.4)/patient (P < .0001) without changing transfusion rates (3% in the 2 periods).

Topics: Aged; Aged, 80 and over; Anemia; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Biomarkers; Blood Loss, Surgical; Blood Transfusion; Drug Administration Schedule; Drug Compounding; Erythropoietin; Female; Ferric Compounds; Hematinics; Hemoglobins; Humans; Infusions, Intravenous; Injections, Subcutaneous; Male; Maltose; Middle Aged; Program Evaluation; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome

Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy.. Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients.. In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs.

Topics: Anemia; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Hemorrhage; Humans; Monitoring, Physiologic; Operative Blood Salvage; Treatment Outcome; Wounds and Injuries

Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients.. In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol.. A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment.. Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.

Topics: Aged; Anemia; Antifibrinolytic Agents; Arthroplasty; Blood Loss, Surgical; Blood Transfusion; Cost-Benefit Analysis; Erythrocyte Transfusion; Erythropoietin; Female; Ferric Compounds; Health Care Costs; Humans; Male; Middle Aged; Postoperative Period; Preoperative Care; Preoperative Period; Retrospective Studies; Tranexamic Acid; Treatment Outcome

Topics: Adult; Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoiesis; Erythropoietin; Hemostasis; Humans; Iron; Orthopedic Procedures; Perioperative Period

Arthroplasties of hip and knee are associated with blood loss, which may lead to adverse patient outcome. Performing arthroplasties in Jehovah's Witness patients who do not accept transfusion has been a matter of concern. We developed a protocol, which avoids transfusion in arthroplasties of Jehovah's Witness patients, and evaluated the feasibility and safety of the protocol.. The target of preoperative hemoglobin was more than 10 g/dL. When preoperative hemoglobin was lower than 10 g/dL, 4000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) were administered until the hemoglobin reached 10 g/dL. When the preoperative hemoglobin was higher than 10 g/dL, 4000 U erythropoietin and 100 mg iron supplement were administered once, before operation. During the operation, cell saver was used. Postoperatively, erythropoietin and iron supplements were administered until the hemoglobin reached 10 g/dL, similar to the preoperative protocol. We evaluated the feasibility of our protocol, perioperative complications and hematologic changes.. From 2002 to 2014, 186 Witness patients visited our department. In 179 patients (96.2 %), 77 total knee arthroplasties, 69 bipolar hemiarthroplasties and 33 total hip arthroplasties were performed. The mean hemoglobin level was 12.3 g/dL preoperatively, 9.4 g/dL on postoperative day 3 and 10.3 g/dL on postoperative day 7. One patient died immediately after the arthroplasty and the remaining 178 patients survived.. Total joint arthroplasty could be done without transfusion using this protocol in most of our patients. The rates of infection and mortality were similar with known infection and mortality rates of arthroplasties. In patients who do not want allogeneic transfusions, our protocol is a safe alternative to perform joint arthroplasties.

Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Clinical Protocols; Erythropoietin; Feasibility Studies; Female; Hemoglobins; Humans; Iron; Jehovah's Witnesses; Male; Middle Aged; Preoperative Care; Recombinant Proteins

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoietin; Female; Hematinics; Humans; Iron; Male; Observational Studies as Topic; Perioperative Care; Postoperative Hemorrhage; Practice Guidelines as Topic; Recombinant Proteins; Risk; Transfusion Reaction; Treatment Outcome

Topics: Aged; Anemia; Aortic Aneurysm, Abdominal; Blood Loss, Surgical; Critical Illness; Epoetin Alfa; Erythropoietin; Ferric Compounds; Ferric Oxide, Saccharated; Glucaric Acid; Hematinics; Humans; Iron Compounds; Jehovah's Witnesses; Male; Recombinant Proteins; Salvage Therapy

The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities.

Topics: Anemia; Anesthesiology; Antifibrinolytic Agents; Blood Banks; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Erythropoietin; Health Care Surveys; Hematinics; Hemoglobins; Hospital Departments; Humans; Iron; Operative Blood Salvage; Organizational Policy; Perioperative Care; Postoperative Hemorrhage; Professional Staff Committees; Recombinant Proteins; Spain

To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoietin; Female; Ferritins; Hematinics; Hemoglobins; Humans; Iron; Male; Middle Aged; Preoperative Care; Recombinant Proteins; Time Factors

Postoperative anemia is a common finding in patients who undergo major surgery, and it can affect early rehabilitation and the return to daily activities. Allogeneic blood transfusion is still the most widely used method for restoring hemoglobin levels rapidly and effectively. However, the potential risks of transfusions have led to the review of this practice and to a search for alternative measures for treating postoperative anemia. The early administration of intravenous iron appears to improve the evolution of postoperative hemoglobin levels and reduce allogeneic transfusions, especially in patients with significant iron deficiency or anemia. What is not clear is whether this treatment heavily influences rehabilitation and quality of life. There is a lack of well-designed, sufficiently large, randomized prospective studies to determine whether postoperative or perioperative intravenous iron treatment, with or without recombinant erythropoietin, has a role in the recovery from postoperative anemia, in reducing transfusions and morbidity rates and in improving exercise capacity and quality of life.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoietin; Female; Ferritins; Hematinics; Hemoglobins; Humans; Iron; Male; Medical Errors; Observational Studies as Topic; Postoperative Care; Postoperative Hemorrhage; Practice Guidelines as Topic; Pregnancy; Puerperal Disorders; Randomized Controlled Trials as Topic; Recombinant Proteins

Preoperative anemia in patients with cancer is highly prevalent, is associated with increased perioperative morbidity and is a risk factor for transfusion. There is evidence that patients who undergo transfusions have higher morbidity, increased cancer recurrence and poorer survival. The pathophysiology of anemia is multifactorial, with an inflammatory component to which chronic blood loss and nutritional deficiencies can be associated. Therefore, preoperative anemia in patients with cancer should be treated appropriately, given that there is sufficient time in the preoperative period. Of the currently available options, parenteral iron is an effective alternative, especially for those types of cancer that have an associated hemorrhagic component.

Topics: Anemia; Biomarkers; Blood Loss, Surgical; C-Reactive Protein; Erythropoietin; Ferritins; Forecasting; Hematinics; Hemoglobins; Humans; Iron; Medical Errors; Neoplasms; Preoperative Care; Recombinant Proteins; Transfusion Reaction

The prevalence of preoperative anemia in major orthopedic surgery is high and is the main predictive factor for allogeneic blood transfusion. The scheduling of a preoperative visit with sufficient notice (at least 3 weeks before surgery), with a blood count test and a basic iron metabolism study, enables us to treat the anemia and/or improve preoperative hemoglobin levels, thereby reducing the need for transfusion and the risks associated with transfusions. Intravenous iron and/or erythropoietin are treatments for optimizing preoperative anemia, with good levels of scientific evidence.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Erythropoietin; Female; Ferritins; Hematinics; Hemoglobins; Humans; Iron; Male; Medical Errors; Orthopedic Procedures; Preoperative Care; Prevalence; Recombinant Proteins; Risk Factors; Transferrin; Vitamins

Repairing hip fractures is one of the most common surgical procedures and has greater morbidity and mortality. This procedure is also a process that involves a greater need for blood products. Numerous factors influence morbidity, mortality and the use of blood products: patient age, concomitant diseases and drug treatments that change hemostasis and hemorrhaging (preoperative, intraoperative and postoperative), which are usually significant. On top of all this is the presence in a high percentage of cases of preoperative anemia, which can have one or more causes. It is therefore essential to establish an appropriate management of perioperative anemia and optimize the transfusion policy. The aim of this review is to briefly analyze the epidemiology of hip fractures as well as establish a basis for treating perioperative anemia and transfusion policies, proposing guidelines and recommendations for clinical management based on the most current studies.

Topics: Anemia; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Ferritins; Fracture Fixation; Hematinics; Hemoglobins; Hip Fractures; Humans; Iron; Male; Medical Errors; Postoperative Hemorrhage; Practice Guidelines as Topic; Preoperative Care; Prevalence; Prospective Studies; Randomized Controlled Trials as Topic; Recombinant Proteins; Risk Factors; Transferrin; Vitamins

Iron deficiency is more common in women due to uterine bleeding, which affects them throughout their fertile life. Additionally, iron needs increase physiologically during pregnancy and breastfeeding. Pregnant women therefore constitute one of the risk groups for iron deficiency. During the postpartum period, iron deficiency is the most common cause of anemia. Longer hospital stays and greater susceptibility to infections are potential consequences of postpartum anemia.

Topics: Anemia; Anemia, Iron-Deficiency; Blood Loss, Surgical; Blood Transfusion; Cesarean Section; Erythropoietin; Female; Gynecologic Surgical Procedures; Hematinics; Hemoglobins; Humans; Iron; Medical Errors; Menstruation; Multicenter Studies as Topic; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Hematologic; Preoperative Care; Prevalence; Prospective Studies; Puerperal Disorders; Randomized Controlled Trials as Topic; Recombinant Proteins

Heart surgery patients have a high prevalence of anemia. Its etiology is multifactorial, and iron deficiency is one of the most common correctable causes. Anemia is an independent risk factor for postsurgical morbidity and mortality. It also predisposes patients to a greater need for transfusions, which increases the associated complications and the use of resources. The etiological diagnosis of anemia is no different from that of other surgical procedures, but the time available for correcting it before surgery is shorter. Studies have been conducted on therapeutic regimens with iron deficiency replenishment with total dose and erythropoiesis-stimulating agents, which enable the rapid correction of anemia and reduce transfusion requirements. There is considerable variability in terms of dosage, adverse effects, administration time and routes, drug combinations and results. New studies are needed to investigate the most ideal regimens for correcting anemia in these patients.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Clinical Trials as Topic; Erythropoietin; Heart Diseases; Hematinics; Hemoglobins; Humans; Iron; Medical Errors; Multicenter Studies as Topic; Observational Studies as Topic; Preoperative Care; Prevalence; Recombinant Proteins; Risk Factors

Iron deficiency in patients with morbid obesity can occur before bariatric surgery due to its inflammatory component and after surgery as the result of implementing the malabsorptive techniques. For patients with morbid obesity, micronutrient deficiencies, such as vitamin B12, iron and folate, should be suspected. Iron deficiency and other hematinics should be corrected, even when anemia has not been established. Normal ferritin levels do not allow us to rule out a possible iron deficiency, given that ferritin can increase due to the chronic inflammatory condition of obesity. After bariatric surgery, patients should take iron supplements; however, these supplements are frequently poorly tolerated. Rapid and effective correction of hemoglobin levels might require the intravenous administration of iron preparations.

Topics: Anemia; Bariatric Surgery; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Hematinics; Hemoglobins; Humans; Iron; Male; Medical Errors; Obesity, Morbid; Practice Guidelines as Topic; Preoperative Care; Recombinant Proteins; Risk Factors

The liberal use of transfusions is not only a risk for patients but also represents a significant healthcare expenditure. The rational use of allogeneic blood transfusions and the use of transfusion alternatives, such as the optimization of preoperative hemoglobin levels, can offer substantial savings to health departments by reducing the cost of transfusions and the morbidity related to the transfusions.

Topics: Anemia; Blood Banks; Blood Loss, Surgical; Blood Transfusion; Cost Savings; Cost-Benefit Analysis; Erythropoietin; Hematinics; Hematologic Tests; Hospital Costs; Humans; Iron; Perioperative Care; Postoperative Complications; Recombinant Proteins; Risk; Transfusion Reaction

The Soonchunhyang University Hospital Bloodless Center was established in 2000, and more than 2,000 bloodless surgeries have been performed there since. In this study, the lowest postoperative Hb/preoperative Hb (Hblow/pre) ratio and mortality rates of patients who underwent bloodless surgery were analyzed for each maximum surgical blood order schedule (MSBOS) category to assess whether MSBOS can be used as a predictor of successful completion of bloodless surgery.. A total of 971 patients were included. MSBOS was defined as the average number of units of RBCs transfused during each elective surgery. We used the Hblow/pre ratio as an alternative to intraoperative blood loss. Frequency of Hblow/pre ratios ≤0.5, use of transfusion alternatives, and mortality rates were compared across MSBOS categories.. Out of the 971 patients, 701 (72.2%) were categorized as type and screen (T&S), 184 (18.9%) as MSBOS 1, 64 (6.6%) as MSBOS 2, and 22 (2.3%) as MSBOS 4. Transfusion alternatives were used by 397 (40.9%) patients. The frequency of the use of simultaneous erythropoietin and iron, hemostatics, acute normovolemic hemodilution, and Cell Saver (Haemonetics corp., USA) was higher in patients in the higher MSBOS categories. Six (0.6%) patients died within 30 days of surgery. Hblow/pre ratios tended to be lower as the level of MSBOS category increased.. Surgeries in the higher MSBOS categories tended to be associated with high blood loss and mortality. Active use of transfusion alternatives is recommended in patients in high MSBOS categories who are scheduled to undergo bloodless surgery.

Topics: Blood Loss, Surgical; Bloodless Medical and Surgical Procedures; Erythropoietin; Hemodilution; Hemoglobins; Hemostatics; Hospitals, University; Humans; Iron; Outcome Assessment, Health Care; Tertiary Care Centers

Topics: Anemia; Austria; Blood Loss, Surgical; Blood Transfusion; Cooperative Behavior; Cost Savings; Erythrocyte Volume; Erythropoietin; Ferric Compounds; Hematinics; Hemoglobinometry; Hemostasis, Surgical; Humans; Interdisciplinary Communication; National Health Programs; Oxygen Inhalation Therapy; Patient Care Team; Preoperative Care; Transfusion Reaction

Topics: Blood Gas Analysis; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion, Autologous; Child; Craniosynostoses; Erythropoietin; Hemodilution; Humans; Intraoperative Care; Lactic Acid; Monitoring, Intraoperative

Calvarial remodeling is typically associated with significant blood loss. Although preoperative erythropoiesis-stimulating agents have proven to significantly decrease the need for blood transfusions, recent data in adults have raised concerns that elevating hemoglobin levels greater than 12.5 g/dl may increase the risk of thrombotic events. This study was designed to assess the risks of erythropoietin in the pediatric population.. Records were retrospectively reviewed from 2000 to 2008 at three major metropolitan children's hospitals of all children undergoing calvarial remodeling after receiving preoperative erythropoietin. Demographic and perioperative outcome data were reviewed, including transfusion reactions, pressure ulcer secondary to prolonged positioning, pneumonia, infection, deep vein thrombosis, cerebrovascular accident, pulmonary embolism, sagittal sinus thrombosis, pure red cell aplasia, and myocardial infarction.. A total of 369 patients met the inclusion criteria (mean age, 0.86±1.1 years). On average, three preoperative doses of erythropoietin were administered (600 U/kg). Iron was also supplemented. No complications associated with dosing were noted, there were no thrombotic events identified, and no other major complications were seen (i.e., death or blindness). Thirty-one patients (8.40 percent) experienced one or more postoperative complications. There was no significant correlation between hemoglobin levels greater than 12.5 g/dl and the occurrence of any noted complication.. With zero thrombotic postoperative complications, the authors estimate the risk of a thrombotic event in the pediatric population to be less than 0.81 percent (95 percent confidence). These data suggest that preoperative administration of erythropoietin in children undergoing calvarial remodeling does not appear to increase the incidence of thrombotic events or other significant complications.. Therapeutic, IV.

Topics: Blood Loss, Surgical; Erythropoietin; Female; Hematinics; Humans; Infant; Male; Orthopedic Procedures; Postoperative Complications; Preoperative Care; Retrospective Studies; Skull; Synostosis; Thrombosis; Treatment Outcome

To compare the postoperative red cell mass as indicated by the hematocrit value of orthognathic surgery patients given iron supplementation and a single preoperative dose of erythropoietin alpha (EPO) and patients who did not receive either EPO or iron supplementation.. Subjects who had a Le Fort I osteotomy (LFI) or a combination of LFI and bilateral sagittal split osteotomy between 2005 and 2008 and were aged at least 13 years were included. Subjects were excluded if they had a history of maxillofacial trauma, a craniofacial syndrome, or a major systemic medical condition. Subjects either had EPO administered with iron supplements before surgery (surgeon A protocol) or received neither (surgeon B protocol). Venous blood samples were taken, in accordance with clinic protocol, before surgery (before administration of EPO) and on postoperative day 1. Multiple linear regression with backward selection was used to analyze the change in hematocrit value. Explanatory variables included group, preoperative hematocrit level, age, gender, length of surgery, blood loss, and crystalloid (fluid replacement) volume.. The study included 178 eligible patients: 86 (48%) had a combination of LFI and bilateral sagittal split osteotomy and 92 (52%) had an isolated LFI. Of the patients, 114 (64%) had EPO/iron supplements administered before surgery whereas 64 did not. The mean change in hematocrit level as an indicator of the change in red cell mass was statistically significantly different (P = .01) for the subjects who received preoperative administration of EPO with iron supplementation compared with those who did not receive EPO plus iron. The administration of EPO plus iron was protective: the decrease in hematocrit level after surgery was smaller for subjects in the EPO group even after we controlled for age, gender, preoperative hematocrit level, length of surgery, blood loss, and crystalloid (fluid replacement) volume.. A single preoperative dose of erythropoietin with iron supplementation resulted in a smaller decrease, on average, in postoperative red cell mass as indicated by hematocrit value in patients with complicated orthognathic surgery procedures.

Topics: Adolescent; Age Factors; Blood Loss, Surgical; Chi-Square Distribution; Dietary Supplements; Erythropoietin; Female; Fluid Therapy; Hematocrit; Humans; Injections, Subcutaneous; Iron; Linear Models; Male; Operative Time; Orthognathic Surgical Procedures; Premedication; Recombinant Proteins; Retrospective Studies; Sex Factors; Young Adult

Revision THA is associated with high blood loss and a high probability of blood transfusion in the perioperative period. In November 2003, government legislation established the Blood Utilization Program at our center to reduce the rate and risks associated with allogenic transfusion.. The purposes of this study were to (1) determine whether the allogenic transfusion rate in patients undergoing revision THA decreased in those who were reviewed preoperatively by the Blood Utilization Program versus those who were not; (2) determine whether tranexamic acid reduced the rate of transfusion; and (3) identify potential perioperative clinical parameters that are associated with an increased risk of blood transfusion.. We included all 159 patients who underwent revision THA from January 2006 to October 2008 having either a socket and/or femoral stem revision except those having only a liner exchange. One hundred and one patients attended the Blood Utilization Program preoperatively and 58 patients did not (ie, they required urgent/emergency surgery).. The Blood Utilization Program referral made no difference in transfusion rate or transfusion amount; however, the transfusion rates and amount were decreased by 8% and one unit, respectively. In patients referred to the Blood Utilization Program, the intraoperative use of tranexamic acid (an antifibrinolytic) was associated with reduced transfusions, regardless of dosage; preoperative erythropoietin tended to reduce transfusions while preoperative oral iron supplements did not.. To further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined.. Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

Topics: Adult; Aged; Aged, 80 and over; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Hip Prosthesis; Humans; Male; Middle Aged; Preoperative Care; Prosthesis Failure; Prosthesis-Related Infections; Recombinant Proteins; Reoperation; Retrospective Studies; Tranexamic Acid

We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.

Topics: Aged, 80 and over; Antigens; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Preservation; Blood Transfusion, Autologous; Cryopreservation; Erythrocyte Transfusion; Erythrocytes; Erythropoietin; Female; Hemoglobins; Hemolysis; Humans; Iron; Patient Care Planning; Recombinant Proteins

Pediatric scoliosis surgery is associated with considerable blood loss and allogenic transfusions. Transfusions contribute to morbidities and cost. A perioperative pediatric blood management program was implemented at our institution. Patients received preoperative evaluation, cell salvage, topical hemostasis, antifibrinolytics, and hypotensive anesthesia.. The study was a 2-year retrospective cohort review of the program's population from September 2007 through August 2009.. A total of 110 scoliosis surgeries were performed with only 34 and 12% of the patients requiring preoperative oral iron and erythropoietin, respectively. Neuromuscular scoliosis patients had more repaired segments and a larger transfusion rate than idiopathic scoliosis patients (36% vs. 1.7%, p = 0.001). Transfused patients had more blood loss relative to their blood volume (p = 0.001) and blood loss was associated with higher Cobb angles (p = 0.04). Logistic regression revealed that blood loss (p = 0.001), number of segments fused (p = 0.004), and lower patient weight (p = 0.007) are associated with increased odds for transfusion. Twelve patients (10.9%) were identified with low von Willebrand activity with a trend toward higher blood losses (p = 0.07) with lower activity levels.. Transfusion requirements in scoliosis patients are dependent on blood loss as determined by Cobb angles and number of segments fused relative to the patients' blood volume as determined by weight. Implementation of a blood management protocol resulted in a low transfusion rate and unexpectedly led to the preoperative diagnosis of a number of patients with low levels of von Willebrand activity.

Topics: Adolescent; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Blood Volume; Body Weight; Cohort Studies; Dietary Supplements; Erythropoietin; Female; Folic Acid; Hemostasis, Surgical; Humans; Iron; Logistic Models; Male; Outcome Assessment, Health Care; Retrospective Studies; Scoliosis; Spinal Fusion; Thrombophilia

  To assess current practices in the management of children undergoing craniofacial surgery and identify areas of significant practice variability with the intent to direct future research..   The perioperative management of infants and children undergoing craniofacial reconstruction surgery can be challenging because of the routine occurrence of significant blood loss with associated morbidity. A variety of techniques have been described to improve the care for these children. It is presently unknown to what extent these practices are currently employed..   A web-based survey was sent to representatives from 102 institutions. One individual per institution was surveyed to prevent larger institutions from being over-represented in the results..   Requests to complete the survey were sent to 102 institutions; 48 surveys were completed. The survey was composed of two parts: management of infants undergoing strip craniectomies, and management of children undergoing major craniofacial reconstruction..   Significant variability exists in the management of children undergoing these procedures; further study is required to determine the optimal management strategies. Clinical trials assessing the utility of central venous pressure and other hemodynamic monitoring modalities would enable evidence-based decision-making for monitoring in these children. The development of institutional transfusion thresholds should be encouraged, as there exists a body of evidence supporting their efficacy and safety.

Topics: Antifibrinolytic Agents; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion, Autologous; Central Venous Pressure; Child; Craniofacial Abnormalities; Craniotomy; Embolism, Air; Endoscopy; Erythropoietin; Health Care Surveys; Humans; Monitoring, Intraoperative; Operative Blood Salvage; Perioperative Care; Plastic Surgery Procedures

The authors present an analysis of specific features of transfusions of erythrocyte containing media in oncological patients. Special attention was given to necessary selection of donor erythrocytes in performing operations with massive intraoperative blood loss. It considerably contributes to a decreased number of posttransfusional reactions and complications. For the recent five years transfusions of erythrocyte containing media to more than 15 thousand patients with surgical treatment were analyzed. Among them the individual selection of donor blood was fulfilled in 2047 cases. Compatible erythrocytes could not be selected in five cases only. In these patients infusions of Perftoran were used as an oxygen carrier both during operation and at the postoperative period.

Topics: Adult; Anemia; Blood Component Transfusion; Blood Donors; Blood Group Antigens; Blood Group Incompatibility; Blood Loss, Surgical; Blood Substitutes; Erythropoietin; Female; Fluorocarbons; Hematinics; Histocompatibility Testing; HLA Antigens; Humans; Male; Middle Aged; Monitoring, Physiologic; Neoplasms; Quality Improvement; Recombinant Proteins; Retrospective Studies

Epoietin (EPO) effectively decreases perioperative blood transfusion requirements. We evaluated the feasibility of using EPO beta to increase haemoglobin levels before total hip replacement (THR) and reduce transfusion.. One hundred and seventy-one patients undergoing primary THR were included in this prospective observational study. Patients with initial haemoglobin level <130 g l−1 received EPO beta subcutaneously in a four-dose regimen. Haemoglobin levels were measured at baseline, before surgery, and at postoperative days 1 and 5.. Twenty-eight patients received EPO beta preoperatively, 143 were not treated including 42 with initial haemoglobin level <130 g l−1. Haemoglobin increased by 29 ± 9 g l−1 in the low Hb + EPO group versus 2 ± 1 g l−1 for the other patients. In the low Hb + EPO group 3.6% were transfused, in the low HB group 45.2% (P = 0.001) and in the normal Hb group 11.9% (P = 0.2).. Preoperative EPO beta increases haemoglobin level and reduces transfusion frequency in anaemic patients before total joint replacement. It could play a major role in the management of perioperative blood loss in orthopaedic surgery.

Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Chi-Square Distribution; Erythropoietin; Female; Hematinics; Humans; Male; Middle Aged; Preoperative Care; Prospective Studies; Recombinant Proteins; Treatment Outcome

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007.. In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively).. The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6–66.1%) as well as knee (24.0–55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3–28.4%) as well as knee arthroplasty (8.9–16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5–51.0%) and knee arthroplasty (15.9–59.3%).. There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Erythropoietin; Hematinics; Humans; Netherlands; Surveys and Questionnaires

Surgical treatment of Jehovah's witnesses is a special challenge for cardiac surgery. The purpose of this study was to evaluate perioperative management and mid-term clinical outcome of Jehovah's witnesses who underwent cardiac surgery.. Between January 1990 and June 2009, 34 Jehovah's witnesses (22 men, mean age 66 +/- 8 years) underwent cardiac surgery. Surgical procedures included 17 coronary artery bypass grafts (CABG): 3 CABG and aortic valve replacements (AVR); 1 CABG and mitral valve plasty (MVP); 6 AVR; 1 subaortic membrane resection; 2 mitral valve replacements (MVR) and 2 MVP; 1 mitro-aortic valve replacement; and 1 cardiac foreign body removal. There were four urgent operations; 14 patients had NYHA class II-III. Sixteen patients received erythropoietin preoperatively. Preoperative haemoglobin (Hb) value was 14.2 +/- 1.4 g/dl.. Extracorporeal circulation time was 127 +/- 66 min, aortic cross-clamping 84 +/- 45 min. Haemoglobin value 24 h after surgery was 11.2 +/- 1.7 g/dl, haematocrit 34.1 +/- 5.2%. None required surgical reoperation for bleeding.Intensive care unit stay was 2.3 +/- 4.3 days, hospital stay 12.3 +/- 10.4 days; there was no hospital mortality. Postoperatively, erythropoietin was administered to 19 patients. Follow-up was completed in 100%. Reoperation was necessary 8 years later in one patient for mitral bioprosthesis degeneration; the patient died 8 months later. All other patients are alive 59 +/- 60 months after surgery; actuarial survival is 100% and 80 +/- 2% at 5 and 10 years, respectively.. In our limited experience, early and late surgical results of Jehovah's witnesses patients are satisfactory. Appropriate preoperative management, optimization of Hb values, intraoperative measures to reduce the risk of bleeding and total blood loss recovery are the goals to achieve these results.

Topics: Aged; Aged, 80 and over; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Critical Care; Erythropoietin; Female; Hematinics; Hematocrit; Hemoglobins; Hemostasis, Surgical; Humans; Italy; Jehovah's Witnesses; Length of Stay; Male; Middle Aged; Postoperative Hemorrhage; Religion and Medicine; Retrospective Studies; Time Factors; Treatment Outcome; Treatment Refusal

A retrospective review.. To review the effectiveness of blood conservation techniques in the spinal fusion of patients that refuse blood transfusion; specifically the Jehovah's witnesses population.. Spinal surgery can be challenging in patients refusing blood transfusion. There is paucity in the literature examining blood conservation techniques in spinal surgery.. The radiographic and medical records of 19 Jehovah's witnesses patients who underwent spinal deformity surgery at a single institution between 2000 and 2003 were reviewed. Patients were assessed for excessive blood loss (EBL), deformity correction, operative time, perioperative complications, and hospital stay. At latest follow-up (mean, 40 months; range, 8-76) the patients were examined for radiographic fusion, progression and complications.. Spinal fusion was attempted in 19 patients, with a mean age of 17 years (range, 10-36 years). All 19 patients were identified through the "Bloodless Surgery Program." Hypotensive anesthesia, hemodilution, and cell saver was employed for all 19 cases. Erythropoietin with supplemental iron was used in 15 patients. Aprotinin was used in 3 patients. EBL and blood returned by cell saver averaged 855 and 341 mL, respectively. Operative times average 315 minutes. The average drop in hemoglobin from after surgery was 3.1 g/dL. There were 2 intraoperative complications: (i) transient loss of somatosensory evoked potential/motor evoked potential signals; and (ii) one surgery abandoned due to EBL. The average spinal deformity correction was 58%. There were 3 postoperative complications, none related to their refusal of a transfusion. 17 patients were available for radiographic and clinic follow-up of at least 24 months. All displayed radiographic fusion without progression.. These blood conservation techniques allow satisfactory completion of deformity surgery on those patients not willing to be transfused and without major anesthetic or medical complications.

Topics: Adolescent; Adult; Blood Loss, Surgical; Blood Transfusion; Child; Epoetin Alfa; Erythropoietin; Female; Follow-Up Studies; Humans; Jehovah's Witnesses; Kyphosis; Male; Radiography; Recombinant Proteins; Retrospective Studies; Scoliosis; Spinal Fusion; Treatment Refusal; Young Adult

To describe the successful perioperative hemostatic management of a Jehovah's Witness patient with hemophilia B and anaphylactic inhibitors to factor IX, undergoing scoliosis surgery.. A 14 (1/2)-yr-old boy with severe hemophilia B who had a history of anaphylactic inhibitors to factor IX was scheduled to undergo corrective scoliosis surgery. He was initially started on epoetin alfa and iron supplementation to maximize preoperative red cell mass. Additionally, he was placed on a desensitization protocol of recombinant coagulation factor IX (rFIX) and was then treated with activated recombinant coagulation factor VII (rFVIIa) during the postoperative period. Tranexamic acid was given concomitantly. The intraoperative blood loss was approximately 350 mL. The nadir hemoglobin concentration was 111 g.L(-1) on postoperative days one and two. On postoperative day 11, the patient was stable and discharged home with a hemoglobin of 138 g.L(-1). He did not require blood transfusion and no adverse events were observed.. The use of rFIX, rFVIIa, erythropoetin, iron, and tranexamic acid before, during and after scoliosis surgery may be a viable and safe option for hemophilia patients with inhibitors, who refuse blood products.

Topics: Adolescent; Antifibrinolytic Agents; Blood Loss, Surgical; Dietary Supplements; Epoetin Alfa; Erythropoietin; Factor IX; Factor VII; Follow-Up Studies; Hematinics; Hemoglobins; Hemophilia B; Humans; Iron; Jehovah's Witnesses; Male; Recombinant Proteins; Scoliosis; Trace Elements; Tranexamic Acid

Blood management strategies is a term used to address a coordinated approach to the management of blood loss in the perioperative period for total joint arthroplasty. The premise of any blood management strategy is that each patient, surgeon, and operative intervention experiences different risks of requiring transfusion, that those risks can be identified, and that a plan can be implemented to address them. A surgeon's decision to transfuse should be based on physiologic assessment of the patient's response to anemia and not on an arbitrary number ("transfusion trigger"). Intervention strategies can be applied preoperatively, intraoperatively, and postoperatively. Patient-specific planning allows for the appropriate use of patient, hospital, and system resources, ensuring that the consequences of anemia are minimized and that the patient's recovery process is optimized.

Topics: Anemia; Arthroplasty, Replacement; Blood Loss, Surgical; Blood Transfusion, Autologous; Disease Management; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Intraoperative Period; Postoperative Period; Recombinant Proteins

Patients undergoing major cancer resections often receive blood transfusions (TFs). Preoperative erythropoietin (EPO) offers the rationale to reduce TFs and related morbidity.. Perioperative TF information was collected prospectively in a single surgeon practice over 5 years.. Three hundred forty-four patients underwent a major procedure, including pancreatic (n = 130, 38%), hepatobiliary (n = 87, 25%), gastroesophageal (n = 69, 20%), and other operations (n = 58, 17%). Median estimated blood loss (EBL) was 375 mL. PRBC TFs were given in 83 cases (24%), at a median of 2 units [1-16]. TF frequency and EBL did not differ between diagnoses. Multivariate TF associations existed for Hgb (P < 0.0001, OR 0.335), EBL (P < 0.0001, OR 1.007), serum Cl (P = 0.004, OR 1.25), serum Na (P = 0.02, OR 0.810), and age (P = 0.04, OR 1.033). TFs (versus no TFs) were linked to major complications (43 versus 20%, P = 0.0002), mortality (12% versus 3%, P = 0.001), and increased LOS (9 versus 7 days, P < 0.0001). A potential benefit for preoperative EPO to avoid TFs could be derived for only 31 patients (9%).. In this low TF rate of 24% for major visceral resections, few preoperative parameters are able to identify subgroups at risk for TFs aside from blood counts. Our data would not support generalized preoperative EPO administration.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anemia; Blood Cell Count; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Gastrointestinal Neoplasms; Hemoglobins; Humans; Male; Middle Aged; Multivariate Analysis; Perioperative Care; Predictive Value of Tests; Prospective Studies; Risk Factors; Treatment Outcome

Blood transfusion is associated with higher postoperative complication. With the availability of autologous blood and erythropoietin, it would be advantageous to identify patients who are at higher risk for requiring blood transfusion. Our aim is to identify possible predictive factors for perioperative blood transfusion in patients undergoing colorectal resection. We examined 206 patients who underwent colorectal resections.. We analyzed factors including preoperative hematocrit, age, history of radiation, type of resection, operative blood loss, additional surgical procedure, surgery duration, and comorbidity.. Forty-one patients (19.9%) received perioperative blood transfusion. Twenty patients (55.6%) with preoperative hematocrit less than 30 received transfusion (p<0.0001). Twenty-one patients (12.4%) with preoperative hematocrit greater than 30 received perioperative blood transfusion. Thirty-three patients (17.9%) under 65 years received transfusion. Eight patients (36.4%) more than the age of 65 received transfusion (p=0.05). Ten patients (16.1%) without any comorbidity received transfusion, whereas ten patients (15.1%) with one comorbidity, ten patients (22.2%) with two comorbidities, and 11 patients (33.3%) with greater than three comorbidities received blood transfusion (p=0.07). In the multivariate analysis, relative risk of perioperative blood transfusion was 3.63 for patients with preoperative hematocrit less than 30 (p<0.0001), 1.26 for patients more than the age of 65 (p=0.49), and 1.07 for each comorbidity (p=0.62). Patients with higher number of comorbidities and age greater than 65 tend to have lower preoperative hematocrit than other patients.. Hematocrit less than 30 is an independent risk factor for requiring perioperative blood transfusion, and patients with hematocrit less than 30 should be considered for autologous blood transfusion and erythropoietin.

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Colon; Colonic Diseases; Erythropoietin; Female; Hematinics; Hematocrit; Humans; Male; Middle Aged; Patient Selection; Perioperative Care; Rectal Diseases; Rectum; Retrospective Studies; Risk Assessment; Risk Factors

Blood transfusion strategies should reduce both blood transfusion and costs. Possible solutions include autologous donation for selected patients and the prescription of erythropoietin (EPO).. We conducted a quality improvement program to examine the effect of a transfusion strategy algorithm in primary knee (TKA) and hip arthroplasty (THA). Our algorithm is presented as a diagram and is based on tolerated and expected blood losses. Patient characteristics, blood loss, transfusions given, autologous blood wastage, and costs were examined during an initial evaluation and after implementation of the algorithm.. Analysis of 302 (initial evaluation) and 173 (post-implementation) arthroplasties demonstrated a 55% reduction in the prescription of autologous blood donation. The proportion of EPO prescriptions increased from 6.6% to 17.3% (P<0.05). There was a 56% overall reduction in transfusions to fewer autologous (32% vs 12%, P<0.0001) and allogeneic transfusions (21% vs 13%, NS). There were 50% fewer wasted autologous blood units (P=0.002) and a 50% reduction in hospital costs (euro345 vs 169) with no significant change in overall costs (euro439 vs 407). Anaesthetists applied the algorithm in 97% of patients, and it is still in use 1 yr after evaluation.. In this study, the implementation of an algorithm for transfusion strategy changed practice and improved quality of care. The costs for EPO, its administration, and monitoring outside hospital were offset by the reduction in hospital transfusion costs.

Topics: Aged; Aged, 80 and over; Algorithms; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Drug Costs; Erythropoietin; Female; France; Health Care Costs; Hospital Costs; Humans; Male; Middle Aged; Quality of Health Care; Recombinant Proteins

This is a retrospective cohort study examining 61 patients with neurogenic scoliosis who underwent anterior and/or posterior spinal instrumentation at the age of 18 and younger.. The purpose of this study is to investigate this finding further by analyzing the effect of recombinant human erythropoietin (rhEPO) on hematocrit, transfusion and complication rates, and the length of intensive care unit (ICU) days in patients with neurogenic scoliosis.. The preoperative use of rhEPO has been shown to decrease perioperative transfusion requirements in many adult and pediatric patients. A recent study at our institution demonstrated the efficacy of rhEPO in pediatric idiopathic scoliosis patients, but suggested the possibility of an "erythropoietin resistance" in the pediatric neurogenic scoliosis population.. The patients' age at the time of surgery, gender, Cobb angle, erythropoietin administration and dosage, hematocrit levels, type of surgery, intraoperative blood loss, duration of surgery, number of vertebrae fused, comorbidities, complications, transfusion status, and the length of ICU days were collected.. Thirty-five (57.3%) children received preoperative rhEPO, whereas 26 patients (42.7%) did not receive rhEPO. The mean preoperative and discharge hematocrit levels in the patients treated with rhEPO were significantly higher than the non-rhEPO group (P = 0.05). There were no significant difference in likelihood of transfusion, complications, and the length of ICU days between the rhEPO and the non-rhEPO groups. A multivariate analysis demonstrated that the number of fused vertebral levels maintained its significance (P = 0.044) and surgical time had a trend toward significance (P = 0.051) in predicting likelihood of transfusion.. The use of rhEPO effectively stimulated erythropoiesis in these patients and yet demonstrated no significant clinical benefit in reducing the likelihood of transfusion in neurogenic patients in this study. More research is necessary to design a transfusion risk reduction protocols that will minimize the exposure of neurogenic scoliosis patients to allogeneic blood products.

Topics: Adolescent; Adult; Anemia; Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Cohort Studies; Erythropoietin; Female; Hematocrit; Humans; Male; Multivariate Analysis; Neuromuscular Diseases; Postoperative Complications; Predictive Value of Tests; Preoperative Care; Recombinant Proteins; Retrospective Studies; Scoliosis

Joint reconstruction surgery is associated with significant blood loss, and patients often require perioperative transfusions. Recombinant human erythropoietin (epoetin) can be used in anemic patients scheduled for elective, noncardiac, nonvascular surgery to reduce the need for transfusions. In the study reported here, patients with a preoperative hemoglobin level of 10 to 13 g/dL were treated with epoetin. Our analysis showed that transfusions were given to 3 (8%) of the 38 patients who received epoetin before surgery and 20 (57%) of the 35 historical controls (P<.001) and that length of hospital stay did not differ significantly between the 2 groups. Our results provide further support for use of epoetin as an effective strategy for reducing exposure to allogenic blood in orthopedic surgery.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Hemoglobins; Humans; Male; Middle Aged; Orthopedic Procedures; Preoperative Care; Recombinant Proteins; Retrospective Studies; Treatment Outcome

Thoraco-abdominal aneurysm repair usually necessitates blood or blood product transfusion which is prohibited in Jehovah's Witnesses. We report the blood conservation strategy used during thoraco-abdominal aneurysm repair in a Jehovah's Witness. This included pre-operative recombinant erythropoietin, per-operative acute normovolaemic haemodilution, cell salvage, aprotinin, restricted heparinisation, left atrial-distal bypass and recombinant factor VIIa. Post-operative haemoglobin levels were maintained, but a left haemothorax necessitated re-thoracotomy on post-operative day 4. Following re-thoracotomy, Hb was 12.0 g.dL(-1) and platelet count 49 x 10(9).L(-1). Recombinant erythropoietin was recommenced. At discharge (day 12), Hb was 10.1 g.d(L-1). The patient remains well at one year. A thoroughly, pre-planned multi-disciplinary blood conservation strategy can be used to undertake high-risk procedures.

Topics: Adult; Anticoagulants; Aortic Aneurysm, Thoracic; Aprotinin; Blood Loss, Surgical; Erythropoietin; Hemodilution; Heparin; Humans; Jehovah's Witnesses; Male; Preoperative Care; Tomography, X-Ray Computed

Venesection of red blood cells in healthy well-trained subjects decreased the maximum oxygen uptake parallel with the reduction in hemoglobin (Hb) level. Based on the large Hb decrease that is seen after total joint surgery, one could expect a decrease in performance as well. The purpose of this study was to investigate whether autologous blood enhanced performance on a bicycle ergometer in patients after total hip arthroplasty.. Nine patients scheduled for elective total hip arthroplasty in an accelerated stay program participated in a preoperative autologous blood donation (PABD) program. Weeks before the scheduled surgery, patients donated 4 units of blood and received standard erythropoietin treatment. Physical fitness was assessed during exercise test on a bicycle ergometer. Each patient was matched with three previously tested patients.. Patients in both groups were 69.0 years old (range, 66-74 years vs. 61-77 years). None of the patients had relevant cardiovascular abnormalities. On average patients received 3.3 units of blood because 3 units were not transfused. The PABD group showed a Hb decrease of 0.5 g per dL (4%) on the fourth postoperative day versus 4.4 g per dL (31%) in the control group. The decline in power output on Day 4 was significantly less in the PABD group compared with the control group (t test, p = 0.026).. From this pilot study it can be concluded that correction of the postoperative Hb decrease was associated with a lower decrease in maximum power output, compared to the control group. On Days 23 and 39, however, the difference in performance between the PABD group and control group had disappeared.

Topics: Aged; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion, Autologous; Body Mass Index; Case-Control Studies; Cohort Studies; Erythropoietin; Exercise Test; Female; Hemoglobins; Humans; Male; Middle Aged; Oxygen Consumption; Physical Fitness; Pilot Projects; Postoperative Period; Preoperative Care; Time Factors

Although it is well known that patients with preoperative hemoglobin levels <13.0 g/dL are at a higher risk for requiring postoperative transfusions, the ideal blood management strategy for this group of patients remains unclear. This study compared preoperative autologous donation with preoperative administration of epoetin alfa as a method to maximize perioperative hemoglobin levels and minimize blood transfusions in these high-risk patients undergoing total knee arthroplasty (TKA). Results show that both preoperative autologous donation and epoetin alfa were successful in decreasing the need for allogeneic blood transfusions following TKA in high-risk patients. Epoetin alfa was more effective in maximizing perioperative hemoglobin levels.

Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Female; Hematinics; Hemoglobins; Humans; Male; Middle Aged; Preoperative Care; Recombinant Proteins; Retrospective Studies; Risk Factors

The majority of Jehovah's Witnesses refuse blood product transfusion, even when it can be lifesaving. Treatment with recombinant human erythropoietin (RHuEPO) is a valuable adjunct in Jehovah's Witness patients undergoing surgery. A number of additional strategies, including acute normovolaemic haemodilution, intra-operative blood salvage and reinfusion, iron and folate supplementation are also utilized to avoid blood transfusion. Critically ill patients have blunted erythropoietin production and decreased endogenous iron availability. This case report reviews the treatment of anaemia in critically ill Jehovah's Witness patients after surgery and discusses the potential need for higher RHuEPO dosing strategies and longer duration of therapy.

Topics: Aged; Anemia; Blood Loss, Surgical; Carcinoma, Adenoid Cystic; Erythropoietin; Female; Hematocrit; Humans; Jehovah's Witnesses; Mouth Neoplasms; Recombinant Proteins; Religion and Medicine

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.

Topics: Blood Loss, Surgical; Blood Transfusion; Craniofacial Dysostosis; Dietary Supplements; Erythropoietin; Hematocrit; Hemostatic Techniques; Humans; Infant; Iron; Recombinant Proteins; Vitamin K

To investigate whether postoperative administration of erythropoietin can safely augment in the rapid restoration of hemoglobin (Hgb) values following major gynecologic surgery.. Thirty-three women were enrolled. They had all undergone gynecologic surgery due to malignant or non-malignant reasons. Because of chronic blood loss, many of these patients were iron depleted. Examinations of hematology, serum chemistry and urinalysis values were obtained. Subcutaneous administration of r-HuEPO, in a dosage of 40,000 IU was initiated on the first postoperative day. One additional injection of 40,000 IU was given on the fourth day after surgery. Contemporarily the patients received orally a polysaccharide-iron complex.. During the early postoperative period three patients that were transfused due to severe anemia and one more that was lost in follow-up were excluded from the study analysis. The remaining 29 patients showed a considerable rise in Hgb counts that reached a median value of 1.9 g/dl within a 20-day period.. The postoperative administration of r-HuEPO in gynecologic surgery in patients where autologous blood transfusions can be avoided is challenging, since it can guarantee an uneventful postoperative period with rapid resuscitation without posing the patient to the well-established risks of transfusions.

Topics: Adult; Aged; Anemia, Iron-Deficiency; Blood Loss, Surgical; Drug Administration Schedule; Erythrocyte Transfusion; Erythropoietin; Female; Ferric Compounds; Greece; Gynecologic Surgical Procedures; Hemoglobins; Humans; Injections, Subcutaneous; Menorrhagia; Middle Aged; Polysaccharides; Postoperative Care; Prospective Studies; Recombinant Proteins

Erythropoietin (rhEPO) has been used in different surgical procedures as a method for saving allogeneic blood, with variable efficacy. Forty consecutive patients entered the pre-operative autologous blood donation (PABD) program, and during donations hemoglobin fell below 115 g/l; they received rhEPO 40,000 U every week for three or four weeks (group 1). As control group, 35 consecutive patients who entered the PABD program were studied; during donations, hemoglobin levels in these patients fell below 115 g/l, but rhEPO was not administered (group 2). Pre-surgery hemoglobin levels were higher in patients who received rhEPO (134 g/l vs. 121 g/l; p<0.0002), and an average of 3.47 doses were administered. The number of transfused autologous units was 1.6 in group 1 and 2.1 in group 2 (p<0.05), while the number of allogeneic units was 0.9 and 0.1, respectively (p<0.0005), so that only 5% of patients treated with rhEPO required some allogeneic unit, as compared to 40% of those who did not receive rhEPO (p<0.0005). There were no relevant adverse effects, but in two patients from group 1, rhEPO treatment had to be discontinued because the level of hemoglobin exceeded 150 g/l. The mean duration of hospital admission was shorter in the patients who received rhEPO than in those who only underwent PABD (8 days vs. 11.8 days; NS). When adequately used, rhEPO is an effective and safe alternative to the use of allogeneic blood.

Topics: Adjuvants, Pharmaceutic; Aged; Algorithms; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Female; Humans; Male; Middle Aged; Recombinant Proteins

There is a lack of consensus with regard to ways to minimize blood transfusions after total knee arthroplasty. We surveyed 434 members of the American Association of Hip and Knee Surgeons, each of whom averaged 18 years in practice and performed an average of between 100 and 150 knee replacements a year, about their preferences and practices regarding blood conservation during total knee arthroplasty. Of those surveyed, only 24% reported that there was a blood conservation program in place at their institutions. Fifty-nine percent of those surveyed routinely asked their patients to donate blood before unilateral and bilateral knee replacements. The amount of blood collected averaged 1.32 units (range, 1-4 units) and 2.04 units (range, 1-4 units) before unilateral and bilateral knee arthroplasty, respectively. Nearly half (47.5%) reported they rarely ever prescribed epoetin alfa because of a combination of cost, time, and labor issues. Furthermore, the majority (84%) has not had any experience with the use of antifibrinolytics. Overall, the mean transfusion rate after unilateral knee replacement was estimated to be less than 5% (range, 0%-20%) whereas the rate after bilateral knee replacement was estimated to be between 10% and 20% (range, 5%-20%).

Topics: Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Health Care Surveys; Hematinics; Humans; Practice Patterns, Physicians'; Recombinant Proteins

Allogeneic blood transfusions (ABT) are often necessary in elective spine surgery because of perioperative blood loss. Preoperative autologous blood donation (PABD) has emerged as the principal means to avoid or reduce the need for ABT. Consequently, a multicentre study was conducted to determine the yield and efficacy of PABD in spine surgery and the possible role of recombinant human erythropoietin (EPO) in facilitating PABD.. We retrospectively reviewed the hospital charts and blood bank records from all consecutive spine surgery patients who were referred for PABD. Data were obtained from two A-category hospital blood banks and one general hospital. Although we collected data from 1994, the analytic study period was from the last quarter of 1995 to December 2003. Fifty-four (7%) out of 763 patients referred for PABD were rejected, and medical records were available for 680 patients who were grouped into spinal fusion (556; 82%) and scoliosis surgery (124;18%). EPO was administered to 120 patients (17.6%). From 1999 to 2003, PABD steadily increased from 60 to 209 patients per year.. Overall, 92% of the patients were able to complete PABD, 71% were transfused, and almost 80% avoided ABT. PABD was more effective in fusions (86%) than in scoliosis (47%). Blood wastage was 38%, ranging from 18% for scoliosis to 42% for fusions. EPO allowed the results in the anaemic patients to be improved.. Therefore, despite the limitations of this retrospective study, we feel that PABD is an excellent alternative to ABT in spine surgery. However, the effectiveness of PABD may be enhanced if associated with other blood-saving techniques.

Topics: Adult; Blood Banks; Blood Loss, Surgical; Elective Surgical Procedures; Erythropoietin; Female; Humans; Male; Middle Aged; Recombinant Proteins; Retrospective Studies; Scoliosis; Spinal Fusion; Spine; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome

The objective of this study was to establish a novel method of preoperative autologous blood donation (PAD) for surgery of gynecologic malignancies, which requires considerable amounts of plasma relative to the red blood cell component. To collect a double volume of plasma over the amount obtained from whole blood without using an aphaeresis system, we first collected 500 ml of whole blood (2.5 units), and centrifuged it. We gave back the resultant red cell component alone, and retained the plasma component. We further collected an additional 500 ml of whole blood, and centrifuged it. The red cell component (2.5 units) was stored in the refrigerator (as a concentrated red cell, CRC). The resultant plasma together with the plasma collected first (5 units) was frozen and stored in the freezer (fresh frozen plasma, FFP), We repeated this procedure at most three times at intervals of 1 week. Erythropoietin was injected once a week and iron tablets were prescribed. Ninety-nine patients undergoing surgery for a gynecological malignancy were subjected to this method and 86 patients without PAD served as a control. We conducted the procedure for PAD without any noticeable side effects. The amount of actual use of allogeneic CRC and FFP were significantly reduced in the PAD group compared with the control group. In particular, 93.6% of the PAD cases who gave 10 or less units of FFP could go without allogeneic FFP. Postoperative serum albumin levels were higher in the PAD group compared with the control. We have established a novel PAD method which can yield a greater volume of FFP relative to CRC, thus meeting requirements for surgery for gynecological malignancies.

Topics: Blood Loss, Surgical; Blood Specimen Collection; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Female; Genital Neoplasms, Female; Hematinics; Hemoglobins; Humans; Patient Selection; Plasma Volume; Preoperative Care; Recombinant Proteins

Topics: Aprotinin; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Clinical Protocols; Erythropoietin; Hemostatics; Humans; Orthopedic Procedures

Topics: Aged; Arthroplasty, Replacement; Blood Loss, Surgical; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Recombinant Proteins

Topics: Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Craniosynostoses; Erythropoietin; Hemoglobinometry; Humans; Infant; Randomized Controlled Trials as Topic; Recombinant Proteins

Current data demonstrate a lack of support for allogeneic transfusion as a reliable means of delivering oxygen. For the ICU patient tolerance of anemia along with aggressive erythropoitin plus iron therapies can restore hemoglobin levels to normal earlier and with fewer morbidities and possibly enhanced survival than by allogeneic transfusion. Additional evidence on anemia treatment comes from case report studies where transfusions are prohibited and patients survived extremely low hemoglobin levels. While synthetic and bioengineered temporary oxygen carriers may soon be approved for clinical use, the current treatment of anemia remains permissive for the conscientious and informed physician. In the past, anemia meant an almost mandatory transfusion. Now, evidence provides the clinician with sufficient alternatives to treat anemic patients without the use of bank blood products at lower costs with excellent survival and with evidence accumulating to suggest better outcomes.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Blood Volume; Erythropoietin; Hemodilution; Hemoglobins; Humans; Intensive Care Units; Jehovah's Witnesses; Postoperative Care; Time Factors; Treatment Outcome

We present a case of surgery in a 2-month-old infant of the Jehovah's Witness (JW) faith weighing 2.8 kg scheduled for left upper lobectomy because of congenital lobar emphysema. He presented with physiological anaemia (haematocrit 33.8%) in accordance with his age. Because of the relative emergency of surgery, a short erythropoietin course was instituted. Recombinant human erythropoietin (rHuEPO) at a dosage of 180 U x kg-1x day-1 was administered for 10 days preoperatively and for 4 days postoperatively. Iron was administered orally and intravenously over the entire perioperative period. No side-effects from either erythropoietin or intravenously administered iron were observed. To our knowledge, this is the first case published of a short perioperative rHuEPO course in an infant.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion; Emphysema; Erythropoietin; Hematocrit; Humans; Infant; Iron; Jehovah's Witnesses; Male; Postoperative Care; Preoperative Care; Recombinant Proteins; Religion and Medicine

Topics: Blood Loss, Surgical; Blood Transfusion; Child; Child, Preschool; Erythropoietin; Humans; Infant; Recombinant Proteins; Transfusion Reaction

Topics: Adult; Anticoagulants; Bandages; Blood Loss, Surgical; Cesarean Section; Christianity; Dalteparin; Erythropoietin; Extracorporeal Circulation; Female; Ferrous Compounds; Humans; Pregnancy; Pregnancy Outcome; Pregnancy, Multiple; Recombinant Proteins; Triplets

Topics: Anemia; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Epoetin Alfa; Erythropoietin; Humans; Preoperative Care; Recombinant Proteins

A giant hemangioma of the tongue was resected in a 16-year-old otherwise healthy young man (ASA I). Despite a total blood loss of 4,300 ml, corresponding to 105% of the patients intravascular blood volume, no allogeneic red blood cells had to be transfused intraoperatively. Besides minimization of intraoperative blood loss with preoperative alcohol injections into the tumor, ligation of large tumor-perfusing arteries, application of fibrin glue, skillful surgical technique, positioning of the surgical field above the level of the heart, controlled hypotension and maintenance of normothermia, acute normovolemic hemodilution (augmented by preoperative administration of recombinant human erythropoetin - rhEpo) and autotransfusion of lost blood were used for recovery of autologous blood. Under the protection of hyperoxia, a decrease of the hemoglobin (Hb) concentration to 4.2 g/dl was bridged by extreme normovolemic hemodilution. No signs of immanent or manifest tissue hypoxia were encountered. Retransfusion of autologous red blood cells was only started when surgical control of bleeding was achieved. Additionally a total of 4 units of fresh frozen plasma were infused for stabilization of plasma coagulation. After a 9-hour surgical duration, the patient was transferred to the intensive care unit, normotensive (with low-dose infusion of norepinephrin) and normothermic with a Hb concentration of 5.6 g/dl. In the face of an increasing lactacidosis 2 units of packed red blood cells were transfused on post surgical day 1.

Topics: Adolescent; Anesthesia, General; Blood Loss, Surgical; Blood Preservation; Blood Transfusion, Autologous; Erythrocyte Transfusion; Erythropoietin; Fibrin Tissue Adhesive; Hemangioma; Hemodilution; Humans; Male; Plasma; Recombinant Proteins; Tissue Adhesives; Tongue Neoplasms

Due to shortage of blood as well as blood-associated risks, blood conservation programs should be implemented.. We compared the use of blood in 109 patients who were included in our program by their surgeons with that in 115 patients who were not recruited by them.. Twenty percent of patients under the program were allo-transfused vs 41% in the other group (p < 0.001). A 67% reduction in homologus blood transfusion was achieved.. The combination of blood conservation techniques can be useful to spare blood, especially in good condition patients or in those with moderate anemia.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Elective Surgical Procedures; Erythropoietin; Female; Humans; Intraoperative Care; Male; Orthopedic Procedures; Preoperative Care; Program Evaluation; Prospective Studies; Recombinant Proteins

Six patients aged from 27 to 62 years were operated for subtotal burn strictures, cancer and glandular polyp of a low-thoracic part of the esophagus using a complex program of non-blood surgery. The following methods were used: collection of autoplasma before surgery by plasmapheresis, collection of autologic packet red cells, normovolemic hemodilution during surgery, use of perftoran for oxygen transport and recombinant human erythropoetin to stimulate erythropoiesis and raise preporative level of hemoglobin. Components of donor blood were not used in these patients. There were no complications associated with these methods. Partial failure of esophagol-colonic anastomosis on the neck was seen in 1 patient. The complex program permits one to avoid completely transfusion of donor blood components in esophagol surgery.

Topics: Adult; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion, Autologous; Erythropoietin; Esophagoplasty; Esophagus; Female; Fluorocarbons; Humans; Male; Middle Aged; Perioperative Care

Topics: Blood Loss, Surgical; Blood Transfusion; Cost-Benefit Analysis; Erythropoietin; Germany; Humans; Recombinant Proteins

Radical retropubic prostatectomy (RRP) has resulted in substantial blood loss and the frequent need for homologous blood transfusion. In this study, the efficacy of autologous blood transfusion, from medical and financial perspectives, was evaluated in patients undergoing RRP.. Between 1994 and 2000, 80 patients with localized prostate cancer underwent RRP in our institute. Based on informed consent, preoperative donation of autologous blood (PDA) was performed in 65 out of 80 patienets. Four or six units were donated during the first 3 years; however, donation units were reduced to a maximum of 4 units since 1997 onwards. The discard rate of donated blood and frequency of homologous transfusion were examined. Changes of hematocrit (Ht) and hemoglobin (Hb) levels through donation and surgery and important factors that may affect postoperative levels of Ht and Hb were evaluated in 56 patients receiving 4-unit donations.. Overall, 2 or 4 units of donated blood were discarded in four patients and homologous transfusion was required in two patients. In 56 patients receiving 4-unit donation, the mean Ht level at predonation was 43.3%. Following donation, this decreased to 35.7%. The administration of recombinant human erythropoietin (rHuEpo) relieved declining Ht levels following donation, but changes in Ht levels after surgery were minor. Important factors related to postoperative decline of Ht and Hb levels were operative time and blood loss.. The program of 4-unit PDA can be performed safely without rHuEpo injection, and it is useful to reduce the risk of requiring homologous transfusion. However, more efficient programs to relieve patient burden and to reduce medical cost are needed.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hematocrit; Hemoglobins; Humans; Male; Middle Aged; Prostatectomy; Prostatic Neoplasms; Recombinant Proteins

Topics: Anemia, Hypochromic; Antirheumatic Agents; Autoimmune Diseases; Blood Loss, Surgical; Christianity; Crohn Disease; Erythropoietin; Folic Acid Deficiency; Hepatitis C, Chronic; Hip Fractures; Humans; Iron; Male; Middle Aged; Paraproteinemias; Premedication; Proteus Infections; Recombinant Proteins; Spondylitis, Ankylosing; Sulfasalazine; Urinary Tract Infections; Vitamins

A multicenter prospective study was conducted to determine whether epoetin alfa could be used to lower transfusion requirements after two-stage exchange arthroplasty for infection. Forty-one consecutive patients undergoing successful two-stage exchange arthroplasty for an infected total knee arthroplasty were enrolled in a prospective study. Epoetin alfa (40,000 units) was administered subcutaneously after prosthesis resection and antibiotic spacer placement. Although there was no difference in the hemoglobin levels before resection arthroplasty or on postoperative Day 3 between the study group and the control group, hemoglobin levels before reimplantation were higher in the patients who received epoetin alfa (12.4 mg/dL; range, 9.3-15.1 mg/dL) compared with the control group (11.3 mg/dL; range, 8.1-14.4 mg/dL). Average increase in hemoglobin level in the interval between stages was higher in the treatment group (3.2 mg/dL; range, -0.7-6.8 mg/dL) than the control group (1.7 mg/dL; range, -1.9-6 mg/dL). The transfusion rate decreased from 83% of patients in the control group to 34% in the study group during reimplantation. In addition, overall incidence of transfusion for either stage improved from 89% in the control group to 44% in the patients treated with epoetin alfa. Perioperative epoetin alfa statistically increased the hemoglobin levels and decreased transfusion rates for patients undergoing two-stage revision for infected total knee arthroplasty.

Topics: Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Knee Prosthesis; Prospective Studies; Prosthesis-Related Infections; Recombinant Proteins; Reoperation

Concern about the side effects of allogeneic blood transfusion has led to increased interest in methods of minimizing peri-operative transfusion. Technologies to minimize allogeneic transfusion include drugs such as aprotinin, desmopressin, tranexamic acid and erythropoietin, and techniques such as acute normovolemic hemodilution, cell salvage and autologous pre-donation.. To survey the current use in Israel of these seven technologies to minimize allogeneic blood transfusion.. Our survey was conducted in 1996-97 in all hospitals in Israel with more than 50 beds and at least one of the following departments: cardiac or vascular surgery, orthopedics, or urology. All departments surveyed were asked: a) whether the technologies were currently being used or not, b) the degree of use, and c) the factors influencing their use and non-use. The survey was targeted at the heads of these departments.. Pharmaceuticals to reduce allogeneic blood transfusion were used in a much higher proportion in cardiac surgery departments than in the other three departments. Pre-operative blood donation was used in few of the cardiac, urologic and vascular surgery departments compared to its moderate use in orthopedic departments. The use of acute normovolemic hemodilution was reported in a majority of the cardiac departments only. Moderate use of cell salvage was reported in all departments except urology where it was not used at all.. There is considerable practice variation in the use of technologies to minimize exposure to peri-operative allogeneic blood transfusion in Israel.

Topics: Aprotinin; Attitude of Health Personnel; Biomedical Technology; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Data Collection; Erythropoietin; Hemodilution; Hemostatics; Hospitals; Humans; Israel; Orthopedic Procedures; Perioperative Care; Practice Patterns, Physicians'; Salvage Therapy; Tranexamic Acid; Transfusion Reaction; Urologic Surgical Procedures; Vascular Surgical Procedures

Cardiac surgery in Jehovah's Witness patients remains a challenge in the presence of concomitant congenital or acquired coagulation disorders and anaemia. We report a case of a 66-year-old female Jehovah's Witness suffering from severe calcified aortic valve stenosis requiring aortic valve replacement. The anaemic patient suffered from concomitant platelet dysfunction and deficiency of factors V and VII due to gammopathy of immunoglobulin G. The patient was preoperatively treated with recombinant erythropoietin in combination with folic acid and iron, which resulted in an increase of the haematocrit from 0.335 to 0.416 after 22 days of treatment. Haemostasis was improved by high dose aprotinin and additional desmopressin, which could be demonstrated to be effective by a preoperative test. The patients intra- and postoperative course was uneventful, her total chest tube loss was 130 ml, and she was able to be discharged without the need of any blood transfusions. The beneficial properties of erythropoietin and desmopressin in Jehovah's Witness patients are discussed.

Topics: Aged; Anemia; Aortic Valve Stenosis; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Deamino Arginine Vasopressin; Erythropoietin; Female; Heart Valve Prosthesis Implantation; Hemostatics; Humans; Jehovah's Witnesses; Preoperative Care; Recombinant Proteins; Religion and Medicine

Coronary artery bypass graft (CABG) surgery accounts for a substantial portion of all allogeneic units of blood transfused. Drugs and autologous blood donation (ABD) are alternative or adjunctive methods for reducing complications and costs induced by allogeneic blood transfusions. Recombinant human erythropoietin (epoetin) has the potential to decrease perioperative need for allogeneic blood during CABG, but its high cost calls for a careful economic evaluation before it can be recommended for widespread use.. A decision tree was used to compare a hypothetical strategy of no epoetin with one in which epoetin was utilized to control blood transfusion needs in CABG; each strategy was tested with and without ABD. The impact of these strategies on both the quality-adjusted life years (QALYs) and costs ($US) was calculated.. Using epoetin alone and with ABD, respectively, avoided the transfusion of 0.61 and 1.35 units of allogeneic blood per patient and saved 0.000086 and 0.000146 QALYs per patient. This made cost-effectiveness (CE) higher than $7 million and $5 million for each QALY saved, respectively. ABD alone cost more than $1 million per QALY saved. If the risk of bacterial infections following allogeneic transfusions was included in the model, epoetin alone cost $6288 per QALY saved, while ABD, both alone and with epoetin, saved money.. On the basis of the existing evidence, neither of the blood-saving strategies modeled was a cost-effective means of avoiding the deleterious health effects of perioperative blood transfusions in CABG. However, if allogeneic blood-related infections were to be considered, both ABD and epoetin would be acceptable interventions.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Computer Simulation; Coronary Artery Bypass; Cost-Benefit Analysis; Decision Trees; Drug Costs; Erythropoietin; Feasibility Studies; Health Care Costs; Humans; Male; Models, Theoretical; Preoperative Care; Recombinant Proteins; Safety; Transfusion Reaction; Virus Diseases

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Hemodilution; Humans; Transfusion Reaction

We carried out sacral en-bloc resection in six patients (three with chordoma; one with pheochromocytoma; one with malignant schwannoma; and one with giant cell tumor) using preoperatively collected autologous blood, to avoid homologous blood transfusion. An average of 3200 ml was collected preoperatively, with patients receiving recombinant human erythropoietin (r-HuEPO), at a total dose of 130 000 units on average. In four patients, we were able to accomplish the surgery without homologous blood transfusion. Postoperatively, the hemoglobin level in these four patients recovered to the pre-collective level in 4.5 weeks, on average. These clinical results indicate that en-bloc sacrectomy, which requires a large volume of blood transfusion, can be accomplished with preoperatively collected autologous blood alone.

Topics: Adrenal Gland Neoplasms; Aged; Blood Donors; Blood Loss, Surgical; Blood Transfusion, Autologous; Chordoma; Erythropoietin; Female; Giant Cell Tumor of Bone; Hemoglobinometry; Humans; Hypotension, Controlled; Male; Middle Aged; Neurilemmoma; Pheochromocytoma; Recombinant Proteins; Sacrum; Spinal Neoplasms

We assessed blood loss and subsequent transfusion associated with nephrectomy performed for suspected renal cell carcinoma to establish guidelines for preoperative autologous blood donation and identify a subgroup of patients that may benefit from erythropoietin administration.. We retrospectively reviewed the charts of 211 patients who underwent partial (73%) or radical (23%) nephrectomy for presumed renal cell carcinoma at our institution between 1990 and 1999. Patients were divided into groups 1-44.5% treated with radical nephrectomy for localized disease, 2-21.3% radical nephrectomy for metastatic lesions invading the renal vasculature or inferior vena cava, 3-8% radical nephrectomy for metastatic disease with locally extensive lesions and 4-26.5% partial nephrectomy for localized lesions. Patient charts were evaluated for preoperative and postoperative hematocrit, estimated blood loss, transfusions received, surgical complications and underlying disease.. Median estimated blood loss was 200, 400, 250 and 555 cc in groups 1 to 4, respectively. However, patients in groups 2 and 3 had a substantially greater range of blood loss than those in groups 1 and 4, respectively. The incidence of those with a blood loss of greater than 1 l. was 7%, 36%, 24% and 11% in groups 1, to 4, respectively. The incidence of those requiring transfusion was significantly lower in group 1 than in groups 2 to 4 (18% versus 44%, 24% and 30%, respectively, p <0.009). Mean transfusion requirement plus or minus standard deviation was significantly greater in groups 2 and 3 than in 1 and 4 (2.3 +/- 1.08, 5.5 +/- 4.4, 11.3 +/- 9.6 and 2.3 +/- 1.7 units, respectively, p <0.05). No significant difference was noted in the change in hematocrit as a result of surgery in the 4 groups (p >0.05). Similarly underlying disease and operative complications did not have a significant effect on blood loss or transfusion (p >0. 05).. Radical or partial nephrectomy for localized renal cell carcinoma leads to consistent and well tolerated operative blood loss that rarely results in the need for substantial transfusion. In contrast, nephrectomy for advanced disease may cause a risk of greater blood loss and subsequent need for the transfusion of multiple units of blood. While preoperative autologous blood donation may have limited value in this regard due to the high cost and number of units needed, preoperative erythropoietin administration may be a viable option. Prospective randomized studies are currently planned.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Blood Loss, Surgical; Blood Transfusion; Carcinoma, Renal Cell; Erythropoietin; Hematocrit; Humans; Kidney Neoplasms; Middle Aged; Nephrectomy; Recombinant Proteins; Retrospective Studies

Topics: Adolescent; Adult; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythrocyte Count; Erythropoietin; Humans; Intraoperative Care; Kidney Failure, Chronic; Kidney Transplantation; Male; Peritoneal Dialysis, Continuous Ambulatory; Postoperative Care; Postoperative Period; Preoperative Care; Recombinant Proteins; Retrospective Studies

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.

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Female; Humans; Male; Middle Aged; Orthopedics; Recombinant Proteins; Transplantation, Homologous

Topics: Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Recombinant Proteins; Reoperation

Topics: Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Recombinant Proteins; Spine

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Child; Cost-Benefit Analysis; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Length of Stay; Recombinant Proteins; Scoliosis; Spine

Because anemia is associated with reduced long-term survival, and because allogeneic transfusion is linked to increased recurrence of disease and reduced rates of long-term survival, alternative options for managing anemia in the orthopedic oncologic patient have been sought. Managing the anemia of cancer is particularly challenging given the many obstacles to employing conventional blood management options. One potential means of treating perioperative anemia in orthopedic oncologic patients involves the use of Epoetin alfa. The clinical utility of Epoetin alfa in this setting, however, must be determined in controlled trials.

Topics: Anemia; Blood Loss, Surgical; Blood Transfusion, Autologous; Bone Neoplasms; Combined Modality Therapy; Epoetin Alfa; Erythropoietin; Hematinics; Humans; Recombinant Proteins; Recurrence; Transfusion Reaction

Topics: Antifibrinolytic Agents; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Deamino Arginine Vasopressin; Erythropoietin; Humans; Tranexamic Acid; Trypsin Inhibitors

The administration of erythropoietin (EPO) can be used to increase a patient's hematocrit (Hct) in the preoperative period and thus possibly preclude the need for allogeneic red cells. However, the exact effect on the postoperative Hct of a given rise in Hct in the preoperative period (and on the avoidance of allogeneic blood) has not been thoroughly evaluated.. Equations were developed on the basis of previously described relationships that allowed the assessment of the impact of a given preoperative Hct increase on the postoperative Hct under a variety of clinical situations.. Equations were derived that related the change in preoperative Hct after the administration of EPO to the final Hct after a given blood loss. In a typical example (blood volume = 5000 mL, pre-EPO Hct of 40%, post-EPO Hct of 45% after blood losses of 1000, 2000, 3000, 4000, 5000, and 6000 mL), an additional 205, 168, 137, 112, 92, and 75 mL of red cells, respectively, would be present postoperatively over the volume in the same patient who did not receive EPO. For a smaller patient, such as a child (blood volume, 2500 mL), an additional 17 mL (5000-mL blood loss) to 83 mL (1000-mL blood loss) of red cells would be present postoperatively. Hemodilution and EPO act synergistically to yield additional postoperative red cell volume.. The use of preoperative EPO with a preoperative increase in Hct results in an increased postoperative Hct after a surgical blood loss. Such a postoperative increase is a function of the volume of blood lost and the patient's blood volume but is independent of the patient's initial Hct. The final postoperative red cell volume increase associated with a preoperative increase in Hct of 1 to 5 percent is limited, however (generally equivalent to a fraction of 1 unit of allogeneic blood). Much of the increase in the patient's Hct vanishes at higher blood losses, and this therapy is most effective with blood loss of <4000 mL. EPO therapy alone may be most effectively used in patients with mild anemia who are undergoing routine surgical procedures that commonly require blood transfusion.

Topics: Blood Loss, Surgical; Blood Volume; Erythropoietin; Hematocrit; Hemodilution; Humans; Mathematics; Models, Biological

Bimaxillary orthognathic surgery and genioplasty are frequently performed to correct dentoskeletal anomalies in otherwise healthy young patients. Until 1990 homologous blood transfusions were routinely necessary for these procedures. The present study describes a protocol of blood-saving measures that was adopted and tested on a continuous sample of 127 patients treated between 1994 and 1997. The protocol comprises acute normovolemic hemodilution, controlled moderate hypotension, positioning the surgical field above the heart level, cell saving, intraoperative homeostasis, preoperative autologous blood donation, administration of recombinant erythropoietin, and acceptance of a low hematocrit perioperatively. This study shows that homologous blood transfusions may be avoided intraoperatively by following the protocol described.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Erythropoietin; Evaluation Studies as Topic; Hemodilution; Homeostasis; Humans; Hypotension, Controlled; Oral Surgical Procedures; Orthognathic Surgical Procedures; Preoperative Care; Prospective Studies; Recombinant Proteins

To avoid homologus blood transfusion, we performed the operation for intra-pelvic malignancy with predeposited autologus blood using recombinant human erythropoietin (rH-EPO).. The seven cases of radical prostatectomy and the 15 cases of total cystectomy were analyzed retrospectively. All cases were given ferrons sulfate/200 mg of iron orally every day to the day before the operation and treated with 24,000 unit of rH-EPO subcutaneously every week. The target volumes of preoperative autologus blood collection were 800 to 1,000 ml and 800 to 1,200 ml for radical prostatectomy and total cystectomy, respectively. For each case, 400 ml blood was collected once a week.. In cases of radical prostatectomy, the preserved blood volume was 885.7 +/- 157.4 ml and 6 out of 7 operations were successfully performed without additional homologus blood transfusion (85.7%). In total cystectomy, the preserved blood volume was 1,033.3 +/- 167.6 ml and 14 out of 15 operations were successfully performed without additional homologus blood transfusion (93.3%). The bleeding volume during operation showed no significant difference compared to control group where used homologus blood transfusion. Postoperative courses were uneventful and there encountered no severe side effects and complications in all our procedures.. Our study indicates that in cases of radical prostatectomy and total cystectomy, the operation with predeposited autologus blood using rH-EPO is possible to be performed in safe. The effect on long term prognosis of malignancy is not clear, however, this technique is helpful able to avoid hazardous issues related to homologus blood transfusion during the operation.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion, Autologous; Cystectomy; Erythropoietin; Humans; Male; Middle Aged; Pelvic Neoplasms; Prostatectomy; Recombinant Proteins; Retrospective Studies

Topics: Blood Loss, Surgical; Blood Substitutes; Blood Transfusion, Autologous; Erythropoietin; Humans; Intraoperative Care; Iron; Preoperative Care; Recombinant Proteins

The Jehovah's Witnesses do not accept allogeneic blood transfusion or certain types of autologous blood transfusion and, therefore, present the orthopaedic surgeon with a challenge in the management of perioperative blood loss. Accepting a patient who is a Jehovah's Witness as a surgical candidate requires the surgeon to be prepared medically to use known techniques to limit red blood cell loss or increase red blood cell mass, to resort to extraordinary means when necessary, and to be prepared philosophically to deal with catastrophic blood loss in a patient who may refuse even potentially life-saving transfusion. Issues pertinent to the management of intraoperative blood loss in the patient who is a Jehovah's Witness require careful delineation and specific treatment guidelines. The authors herein review their past and current experiences in the perioperative blood management of this patient population in an attempt to address this need.

Topics: Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Christianity; Contraindications; Elective Surgical Procedures; Erythropoietin; Hematocrit; Hemoglobins; Humans; Patient Care Planning; Preoperative Care; Recombinant Proteins; Reoperation; Safety

Due to the discovery in the 1980s that blood transfusion can transmit HIV, there has been increased interest in technologies that reduce the amount of allogeneic blood used during and after surgery. These technologies include drugs (aprotinin, tranexamic acid, epsilon-aminocaproic acid, erythropoietin), devices (cell salvage), and techniques (acute hemodilution, predeposited autologous donation). The purpose of this study was to ascertain the degree of practice variation, if any, that exists for eight technologies in nine countries in orthopedic and cardiac surgery.. In each country, either all hospitals or a random sample of hospitals with medical/surgical beds were surveyed between 1995 and 1997. Two instruments were used. The first instrument was a postcard that asked recipients whether the technologies were currently being used in their hospital for orthopedic and/or cardiac surgery to reduce perioperative allogeneic transfusion. The second questionnaire elicited information regarding the degree of use both in qualitative and quantitative terms. Data were collected, entered, and analyzed in each country, with summary results submitted to the Canadian coordinating center on a standardized data collection form.. Pharmaceuticals were generally used in a much smaller proportion of hospitals in orthopedic than in cardiac surgery. Aprotinin and tranexamic acid were the drugs most frequently used in cardiac surgery. Nonpharmacological technologies were used to a greater degree than drugs in orthopedic surgery, although there was wide variation among technologies and countries. Acute hemodilution and cell salvage were used in a greater proportion of hospitals for cardiac surgery than orthopedic surgery.. The results of this survey indicate that there is considerable practice variation in the use of technologies to minimize exposure to perioperative allogeneic transfusion within and between countries.

Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Erythropoietin; Europe; Hemodilution; Hemostatics; Humans; Israel; Japan; Medical Laboratory Science; North America; Orthopedic Procedures; Practice Patterns, Physicians'; Surveys and Questionnaires; Transfusion Reaction; Treatment Outcome

We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion.

Topics: Adolescent; Blood Loss, Surgical; Blood Transfusion, Autologous; Child; Christianity; Erythropoietin; Female; Ferritins; Hematocrit; Hemoglobins; Humans; Iron; Monitoring, Intraoperative; Orthopedic Procedures; Recombinant Proteins; Religion and Medicine

Topics: Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Blood Volume; Erythropoietin; Humans; Intraoperative Care; Postoperative Care

To develop indications for the preoperative use of recombinant erythropoietin (rHuEPO) alone and in conjunction with preoperative autologous donation (PAD).. A 2-round modified Delphi-consensus process.. Nine physicians representing multiple clinical specialties, practice environments and geographic locations.. From evidence tables and a literature summary (MEDLINE database from January 1985 to August 1996) provided and using the RAND-UCLA appropriateness method, the physicians developed 264 indications for the preoperative use of rHuEPO by permuting 7 clinical factors (age, history of transfusion or antibody incompatibility, hemoglobin level, anemia of chronic disease, expected blood loss, presence of cardiovascular or cardiopulmonary disease and patient anxiety). These indications were rated on a 9-point appropriateness scale. Median scores and measures of agreement were determined.. The significance of cost constraints or cost and blood supply constraints and the impact of each clinical factor on the ratings as judged by statistical analysis.. Of the 264 indications, 54% were rated appropriate, 18% uncertain and 28% inappropriate. Expected blood loss had the greatest impact on the ratings (high expected blood loss had a 5.9 point more appropriate rating on the 9-point scale than low expected blood loss [p < 0.0001]). Preoperative hemoglobin level also significantly influenced the ratings (p < 0.0001). Compared with the clinical context, the ratings under the cost constraint were 1.0 less appropriate (p < 0.0001) for rHuEPO alone and 1.2 less appropriate for rHuEPO and PAD (p < 0.0001). The ratings for patients with moderate expected blood loss were significantly influenced by the cost constraint (less appropriate).. Expected blood loss and preoperative hemoglobin level were the best indicators of rHuEPO appropriateness. Different contexts modify the appropriateness ratings of an expensive drug like rHuEPO.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Canada; Delphi Technique; Drug Utilization Review; Erythropoietin; Hemoglobins; Humans; Preoperative Care; Recombinant Proteins

The effects of low dose aprotinin (Trasylol) and preoperative administration of recombinant human erythropoietin (EPO) were evaluated in 144 patients undergoing cardiopulmonary bypass divided into four groups. Group I (n = 43) received a subcutaneous administration of EPO (18,000 U) one week before operation and intraoperative administration of low-dose aprotinin (mean; 1.38 +/- 0.26 x 10(6) kallikrein inactivator units; KIU) from extracorporeal circulation, group II (n = 39) received only preoperative administration of EPO, group III (n = 28) received only intraoperative administration of low-dose aprotinin (mean; 1.46 +/- 0.25 x 10(6) KIU), and group IV (n = 34) were not administered either drug. Compared with group IV, the intraoperative blood loss was significantly lower in group I (p < 0.01), and in group II or III (p < 0.05). The postoperative drainage in 24 hours was significantly lower in groups I and III receiving aprotinin than in the other groups. The mean volume of total homologous blood transfusion and the percentage of cases not requiring a homologous blood transfusion in each group was, respectively, 74 +/- 235 ml and 88.4% in group I, 282 +/- 1289 ml and 87.2% in group II, 414 +/- 584 ml and 60.7% in group III, and 976 +/- 1931 ml and 44.1% in group IV. Significant differences were recognized between group I and group IV (p < 0.05). These findings indicate that when used in combination, both drugs reduce blood loss and the need for a homologous blood transfusion more effectively than either drug alone.

Topics: Aged; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Erythropoietin; Female; Hemostatics; Humans; Male; Middle Aged; Recombinant Proteins

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

Topics: Anemia; Anesthesia, Epidural; Blood Loss, Surgical; Blood Transfusion; Christianity; Contraindications; Elective Surgical Procedures; Epoetin Alfa; Erythropoietin; Female; Hematinics; Humans; Operating Rooms; Perioperative Nursing; Recombinant Proteins; Treatment Refusal; United States

The efficacy of the administration of recombinant human erythropoietin (rHuEPO) in the treatment of anaemia in critically ill surgical patients refusing red cell transfusions requires further documentation. Herein, we report the outcome of 5 consecutive severely anaemic Jehovah's Witness patients (lowest haemoglobin concentration 27 g/1), who were discharged from the hospital in good condition after treatment. RHuEPO (50-280 U/kg body weight) was daily administered to 4 of the patients, who either exhibited preoperative anaemia or developed postoperative anaemia refractory to endogenous EPO probably due to inflammation. RHuEPO treatment was followed by a steep rise in reticulocytes and haemoglobin concentration. The fifth patient, who exhibited no signs of systemic inflammation following emergency hemicolectomy, was also treated with intravenous iron, but not with rHuEPO. His blood haemoglobin concentration rose from 27 g/l to 92 g/l in 3 wk. These observations indicate that the administration of rHuEPO is justified in the management of life-threatening anaemia, although only on a humanitarian basis, because there is no predictor for the possible spontaneous recovery.

Topics: Adult; Aged; Anemia; Blood Loss, Surgical; Blood Transfusion; Christianity; Erythropoietin; Female; Humans; Male; Middle Aged; Recombinant Proteins; Treatment Refusal

Topics: Blood Loss, Surgical; Blood Transfusion; Erythropoietin; Hematinics; Hemostasis; Humans; Recombinant Proteins; Surgical Procedures, Operative

Topics: Aprotinin; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Contraindications; Critical Illness; Drainage; Erythropoietin; Evaluation Studies as Topic; Hemodilution; Hemostatics; Humans; Hypotension, Controlled; Intraoperative Care; Iron; Patient Care Planning; Plasmapheresis; Postoperative Care; Posture; Preoperative Care; Quality Control; Risk Factors; Serine Proteinase Inhibitors

A 24-year-old man with an osteolytic lesion of the ischium was referred to the authors' institution. Computed tomography and magnetic resonance imaging studies showed that the lesion extended to and involved the subchondral bone of the acetabulum. Histologic examination of the biopsy specimen revealed giant cell tumor of bone. Following the biopsy, autologous blood was collected 4 times with recombinant human erythropoietin treatment definitive surgery was performed. Three weeks after the biopsy, the lesion was curetted and bone cementation was performed. The total blood loss during surgery was 3100 ml, which was replaced successfully with stored autologous blood without the need for homologous blood transfusion. The authors believe that without the erythropoietin treatment, autologous blood could have been collected only 3 times instead of 4 times, and the patient would have needed homologous blood.

Topics: Adult; Blood Loss, Surgical; Blood Transfusion, Autologous; Bone Neoplasms; Erythropoietin; Giant Cell Tumor of Bone; Humans; Ischium; Male; Preoperative Care; Recombinant Proteins

A 46-yr-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.

Topics: Blood Loss, Surgical; Blood Transfusion; Christianity; Erythropoietin; Female; Hemoglobins; Humans; Liver Cirrhosis, Biliary; Liver Transplantation; Middle Aged; Recombinant Proteins; Time Factors

The efficacy of homologous blood reduction in consecutive elective cardiac surgery by four different autologous transfusion methods was described. One hundred forty patients were divided into five different groups. No autologous blood transfusion in group A (22 cases), intraoperative autotransfusion with Cell Saver in group B (24 cases), additional intraoperative hemodilution method in group C (25 cases), additional preoperative predonation two weeks before operation in group D (15 cases), and predonation one week before operation with recombinant human erythropoietin administration in group E (55 cases) were performed. In group E, the criterion for patient selection of predonation was widely indicated (hemoglobin > 10 g/dl, body weight > 40 kg) and the period of the predonation technique was shorter compared with previous reports. The total homologous blood transfusion volume and the rate of the patients without homologous blood in each groups was 2216 +/- 1888 ml, 14.3% in group A, 2297 +/- 1789 ml, 4.2% in group B, 774 +/- 1043 ml, 36% in group C, 399 +/- 683 ml, 64.3% in group D, 135 +/- 276 ml, and 76.3% in group E, respectively. There were significant differences between group A, B or C and group D (p < 0.01), group A, B or C and group E (p < 0.001), and group D and group E (p < 0.05) with total homologous blood volume and between group A or B and group D (p < 0.01), group A or B and group E (p < 0.001), group B and group C (p < 0.05), and group C and group E (p < 0.01) with the rate of the patients without homologous blood. The reduction of homologous blood volume by patients was 1500 ml by the intraoperative hemodilution method, 370 ml by the preoperative prodonation technique, and 260 ml with predonation using erythropoietin. Ten of the thirteen patient (76.9%) who required homologous blood transfusion in group E had anemia (Hb < 12 g/dl) at preoperative blood pooling or postoperative massive bleeding (total mediastinal drainage > 1000 ml). Elongation of the predonation period before operation or postoperative autotransfusion of mediastinal shed blood and intraoperative aprotinin administration in such patients should be considered to reduce homologous blood transfusion.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Elective Surgical Procedures; Erythropoietin; Female; Humans; Male; Middle Aged

Open-heart surgery has been performed since 1975 on 25 patients who are Jehovah's Witnesses by religion. The patients' ages ranged from 6-60 years, and their body weights from 18-51 kg. Surgical procedures included correction of congenital heart disease in 14 patients and valve repair or replacement in 11. Six procedures were reoperations. The lowest mean haematocrits, during perfusion and the postoperative period, were 22.7% (range 15.0-31.0%) and 27% (range 16.0-36.0%), respectively. Twenty-four patients survived and are alive and well. One patient died of low output failure before discharge. The blood return system reduced blood loss. Five of the patients who underwent cardiac surgery received recombinant erythropoietin before and after surgery, leading to higher postoperative haematocrits. In one patient, a haematocrit which fell to 16.9% after surgery was raised to 27% by administration of erythropoietin, without blood transfusion. In two recent cases, high doses of aprotinin were used during surgery, resulting in better haemostasis after cardiopulmonary bypass.

Topics: Adolescent; Adult; Blood Loss, Surgical; Child; Christianity; Erythropoietin; Female; Heart Defects, Congenital; Heart Valve Diseases; Hematocrit; Humans; Male; Middle Aged; Platelet Count; Postoperative Hemorrhage; Recombinant Proteins; Religion and Medicine; Reoperation; Survival Rate

Five Jehovah's Witnesses (one man and four women) were managed with revision total hip arthroplasty. The average age of the patients at the time of the index operation was 66.4 years (range, fifty-eight to seventy-eight years). All of the patients received subcutaneous injections of recombinant human erythropoietin before the operation, at an initial dose of 100 international units per kilogram of body weight three times a week. The duration of preoperative treatment was determined by the hematocrit at the time of presentation. The hematocrit was monitored weekly, beginning with the second week of treatment, and the dose was adjusted accordingly until the time of the operation. Erythropoietin therapy was discontinued if the hematocrit exceeded 0.45 at any time. The hematocrit before the erythropoietin therapy was begun, at the time of admission to the hospital (one or two days preoperatively), immediately postoperatively, and at the time that the patient was discharged were recorded for this study. All five revision total hip arthroplasties were performed successfully without a blood transfusion. No patient had any complications associated with an excessive loss of blood or a low hematocrit. The average hematocrit was 0.395 (range, 0.317 to 0.447) before the erythropoietin therapy was begun and was 0.476 (range, 0.431 to 0.509) after treatment with erythropoietin and before the operation (that is, at the time of admission to the hospital). The average duration of erythropoietin therapy was twenty-six days preoperatively and 3.6 days postoperatively. The average hematocrit was 0.368 (range, 0.272 to 0.424) immediately after the operation and was 0.308 (range, 0.294 to 0.327) at the time of discharge from the hospital. No patient had evidence of deep venous thrombosis. This study illustrates that it is possible and apparently safe to optimize the hematocrit, by use of erythropoietin, in a patient who is scheduled for an operation. This may be particularly beneficial to a patient with anemia who has failure of a total hip arthroplasty. A relatively high hematocrit (0.45 to 0.50) preoperatively provides a relative margin of safety to a procedure that frequently involves a great deal of intraoperative blood loss. The use of erythropoietin preoperatively is particularly suited to joint replacements and revisions because of their elective nature and the moderately flexible timing associated with these procedures.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Christianity; Erythropoietin; Female; Hematocrit; Hemoglobins; Hip Joint; Hip Prosthesis; Humans; Male; Middle Aged; Premedication; Recombinant Proteins; Reoperation; Treatment Refusal

Topics: Adult; Aged; Blood Loss, Surgical; Christianity; Deamino Arginine Vasopressin; Diuretics; Erythropoietin; Female; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Hemorrhage; Religion and Medicine; Sweden

Erythropoietin, the hematopoietic growth factor, is synthesised in the kidneys and liver and regulates red blood cell production. Within the last few years, recombinant DNA technology has produced synthetic erythropoietin (rhEPO). Some patients, especially Jehovah's Witnesses, will not accept blood transfusion. The perioperative administration of rhEPO increases the patients' hematocrit (HCt) to a higher than physiological level.. We report a case of a 66-year-old female Jehovah's Witness who refused blood transfusions and responded favourably to rhEPO treatment. A total hip arthroplasty was planned. A pretreatment hemoglobin level (Hb) of 13.7 g/dl and HCt of 43% were documented. After preoperative subcutaneous application of 5000 I.E. rhEPO three times per week and daily oral substitution of 300 mg ferrous sulfate over a period of 3 weeks, the Hb increased to 15.5 g/dl and the HCt to 49%. The operation was carried out after the ninth application of rhEPO. Postoperatively, the Hb concentration was 11.8 g/dl and the HCt 35%. Therefore, postoperative administration of rhEPO was not considered indicated. No side effects of rhEPO application were noted. The patient left hospital on the 10th postoperative day.. The case report describes perioperative management using human rhEPO in Jehovah's Witnesses. Treatment with rhEPO increases preoperative Hb levels to a point making it possible to compensate for operative blood loss. RhEPO combined with daily iron substitution may be useful in patients who refuse transfusion based on religious convictions.

Topics: Aged; Blood Loss, Surgical; Christianity; Erythropoietin; Female; Hematocrit; Hemoglobinometry; Hip Prosthesis; Humans; Intraoperative Period; Recombinant Proteins; Reticulocyte Count

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Christianity; Erythropoietin; Female; Hemodilution; Humans; Male; Middle Aged; Recombinant Proteins; Religion and Medicine; Treatment Refusal

A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.6 g.dL-1 and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g.dL-1 and haematocrit to 33% Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.

Topics: Acute Disease; Adult; Anemia, Hypochromic; Blood Loss, Surgical; Christianity; Erythropoietin; Femoral Artery; Femoral Fractures; Femoral Vein; Hemoglobins; Humans; Male; Recombinant Proteins; Time Factors

This report describes the peri- and postoperative management of a patient with a critical blood loss (hemoglobin of 22 g/l) as a consequence of a surgical intervention, i.e. a radical resection of an advanced malignant gynecological tumor. The patient refused autologous and homologous blood transfusions for religious reasons (Jehovah's Witness). During surgery, hemodilution and cell salvage were used. Postoperatively she developed coagulopathy and hemorrhage with the lowest hemoglobin value of 22 g/l. The patient recovered under a therapy regimen of recombinant human erythropoietin and parenteral iron. The hemoglobin values returned to the lower normal range within 4 weeks. Consequences of hypoxia could not be seen.

Topics: Adult; beta-Thalassemia; Blood Loss, Surgical; Carcinoma, Squamous Cell; Christianity; Combined Modality Therapy; Erythropoietin; Female; Hemodilution; Hemoglobinometry; Hemorrhage; Humans; Iron; Postoperative Complications; Religion and Medicine; Uterine Cervical Neoplasms

Topics: Adult; Blood Loss, Surgical; Blood Transfusion, Autologous; Erythrocyte Transfusion; Erythropoietin; Hematocrit; Hemodilution; Hemoglobins; Humans

Conservative use of allogeneic red blood cell (RBC) transfusion is a growing trend in cardiovascular surgery. Recent advances in blood conservation measures have reduced, and in some cases eliminated, the need for allogeneic RBC transfusions in some of these patients. Reduced reliance on allogeneic RBC transfusion requires close collaboration among the clinical pathology, anesthesia, and surgery services managing the patient. Preoperative conservation measures include donation of autologous blood and treatment with recombinant human erythropoietin (Epoetin alfa). Meticulous surgical technique, moderate hemodilution, aprotinin, hemostatic techniques, blood salvage, and autotransfusion are intraoperative measures that can reduce blood loss. Postoperatively, even severe blood deficits can often be restored with adequate diet and rest and the use of actinics.

Topics: Anticoagulants; Aprotinin; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Christianity; Erythrocyte Transfusion; Erythropoietin; Hemodilution; Hemostatic Techniques; Hemostatics; Heparin; Humans; Hypertension; Hypothermia, Induced; Intraoperative Period; Monitoring, Physiologic; Postoperative Care; Preoperative Care; Recombinant Proteins

The orthopedic surgeon has several options available for blood conservation. Preoperative autologous donation (PAD) of blood is a cost-effective measure when the cost of managing transfusion-transmitted infectious disease is considered; overuse and underuse are expensive problems, however. Hemodilution, while used successfully in prostate surgery, is logistically impractical in joint replacement centers. Intraoperative blood salvage, although costly, is useful in orthopedic procedures when the anticipated blood loss is > 1,000 mL. Reinfusion of postoperative drainage that has been filtered and washed is being used in some orthopedic procedures. Studies are under way to determine whether this method of blood conservation alters transfusion requirements. Recombinant human erythropoietin (Epoetin alfa) has a role in elective procedures with significant blood loss, including complex revision joint replacement, bilateral joint arthroplasty, and spinal fusion. Preoperative Epoetin alfa administration enhances preoperative autologous blood collection and increases perioperative red blood cell mass.

Topics: Blood Loss, Surgical; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoietin; Hemodilution; Humans; Orthopedics; Postoperative Care; Preoperative Care; Recombinant Proteins

Analysis of the net costs, efficacy, and cost-effectiveness of preoperative autologous blood donation (PAD), versus acute normovolemic hemodilution (ANH), in patients undergoing radical prostatectomy is presented. Currently, PAD is a standard of care for patients undergoing radical prostatectomy. Comparison of PAD with ANH showed no differences in risks or outcome, but ANH was less expensive. Hemodilution is a simple, safe, convenient, and effective alternative to PAD. The use of recombinant human erthropoietin in conjunction with PAD and ANH has optimized perioperative hematocrits and further minimized exposure to allogeneic blood. Intraoperative blood salvage, lower transfusion triggers, and other blood conservation strategies are discussed. The most cost-effective techniques currently available for decreasing allogeneic blood transfusions appear to be avoidance of blood loss, increased tolerance for decreased HCT levels, and autologous blood procurement via ANH.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Cost-Benefit Analysis; Erythropoietin; Hematocrit; Hemodilution; Humans; Intraoperative Period; Preoperative Care; Recombinant Proteins; Urologic Diseases

The rates of recovery of red blood cell mass after surgery were compared in three groups of orthognathic surgery patients: 12 patients not receiving transfusions during Le Fort I osteotomy, 10 patients receiving transfusions during Le Fort I osteotomy, and 25 patients undergoing bilateral sagittal split osteotomy. Patients in these groups lost a mean of 421, 455, and 191 mL of blood, respectively, during surgery. Both groups of patients undergoing Le Fort I osteotomy donated a unit of blood prior to surgery, while the patients undergoing bilateral sagittal split osteotomy did not. A control group consisted of 77 presurgical orthognathic patients who donated a unit of blood (450 mL) a mean of 11 days prior to surgery. Among the control group, 38 had recovered red blood cell mass prior to surgery. The patients undergoing Le Fort I osteotomy recovered red blood cell mass after surgery more quickly than did the patients undergoing bilateral sagittal split osteotomy, despite having lost twice as much blood. This unexpected finding can be attributed to the need to lose sufficient red blood cell mass to stimulate the erythropoietic system. The patients undergoing Le Fort I osteotomy experienced two challenges to the system, predonation of blood and greater blood loss during surgery, resulting in a great enough decrease in red blood cell mass to stimulate the release of erythropoietin. Patients undergoing bilateral sagittal split osteotomy did not exceed this threshold. None of the differences among the groups were statistically significant, possibly because of the few number of subjects.

Topics: Adult; Blood Donors; Blood Loss, Surgical; Blood Transfusion; Case-Control Studies; Erythrocyte Volume; Erythropoietin; Hemoglobinometry; Humans; Mandible; Maxilla; Orthognathic Surgical Procedures; Osteotomy; Osteotomy, Le Fort; Postoperative Period; Time Factors

Despite recent advances in blood conservation techniques, major risks persist for excessive bleeding and blood transfusion after open heart operations. We reviewed the records of 100 consecutive patients undergoing first-time coronary artery bypass grafting at our institution to define these risks and develop a multimodality blood conservation program based on the results. This program was subsequently applied on a prospective basis to a select group of patients who refuse blood transfusion on religious grounds (Jehovah's Witnesses [JW]) (n = 15). Encouraging initial results with coronary artery bypass grafting in this group (n = 8) led to the application of the program to more complex operations (n = 7), including repeat bypass grafting with use of the internal mammary artery, repeat mitral valve replacement, aortic and mitral valve replacement with coronary artery bypass grafting, mitral valve replacement with bypass grafting, chronic type 1 dissection repair, aortic valve replacement, and atrial septal defect repair in 1 patient each. The blood conservation program employed in these patients included the use of (1) aprotinin (full Hammersmith regimen), (2) high-dose erythropoietin, (3) "maximal"-volume intraoperative autologous blood donation, (4) low-prime cardiopulmonary bypass, (5) exclusive use of intraoperative cell salvage, and (6) continuous reinfusion of shed mediastinal blood. There were no deaths in the JW group. Thromboembolic complications consisted of a transient posterior circulation stroke in only 1 patient (dissection repair). No blood or blood products were transfused compared with the transfusion of 5.1 +/- 7.8 units (mean +/- standard deviation) in the 100 primary coronary bypass patients in whom the blood conservation program was not employed.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aprotinin; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Christianity; Erythropoietin; Hematocrit; Humans; Prospective Studies; Retrospective Studies

The treatment rationale of a burn victim (35% TBSA) who was child of Jehova's witnesses is described. Following a combined approach including erythropoetin and blood saving surgical techniques we were able to excise and graft the burn areas without blood transfusion. An extremely low hemoglobin of 3.4 g/dl was tolerated postoperatively and showed an increase to 10.9 g/dl 25 days later when the child was dismissed from the burn unit in stable condition. Possibilities to minimize blood loss and to avoid blood transfusions are discussed.

Topics: Blood Loss, Surgical; Blood Transfusion; Burns; Child, Preschool; Christianity; Debridement; Erythropoietin; Female; Hemoglobinometry; Humans; Infusions, Intravenous; Iron-Dextran Complex; Skin Transplantation; Treatment Refusal

Conventional blood conservation techniques have been insufficient to decrease blood transfusion requirement in open-heart surgery. Blood conservation and erythropoietin administration were performed to avoid homologous blood transfusion. Intraoperative autotransfusion has been routinely used in cardiac operations with cardiopulmonary bypass in our hospital. To evaluate the effect of conservation techniques, 286 patients were divided into four groups. In group I (23 patients), autologous whole blood was drawn and saved one to two weeks before operation. In group II (50 patients), erythropoietin preparation was given subcutaneously once a week and autologous blood conservation was also performed in the same manner as group I. In group III (48 patients), intra-operative hemodilutional autologous blood transfusion was performed. In group IV, as a control group (165 patients), only intra-operative autotransfusion was used. Homologous blood transfusion was avoided in 83% of group I patients, in 90% of group II, in 82% of group III, and 29% of group IV. In addition, in group II the hemoglobin value at the time of discharge was significantly higher than those of other groups (p < 0.05-0.01). Thus, conventional blood conservation techniques plus subcutaneous administration of erythropoietin was very effective to increase the rate of "non-blood" open-heart surgery.

Topics: Aged; Blood Loss, Surgical; Blood Transfusion, Autologous; Cardiac Surgical Procedures; Erythropoietin; Humans

Topics: Blood Loss, Surgical; Blood Transfusion; Burns; Child, Preschool; Christianity; Erythropoietin; Female; Humans; Recombinant Proteins

Preserved autologous transfusions have been performed for elective pulmonary and mediastinal surgery to prevent the adverse effects of homologous transfusions. Autologous blood was collected preoperatively from 144 patients. The collected blood volume ranged from 400 to 1,600 ml with a mean volume of 544 ml. In four patients with benign diseases, 1,200 to 1,600 ml of blood was collected using 3,000 U of intravenous recombinant human erythropoietin (rh-EPO) administered every other day. One hundred twenty-three of these patients (85 percent) did not require a homologous transfusion. In the 84 patients undergoing either a pneumonectomy, lobectomy, or segmentectomy, 68 (81 percent) avoided homologous blood exposure. A patient with rh-EPO who bled 2,000 g during surgery received an autotransfusion of only 1,400 ml and his postoperative course was uneventful. Preserved autologous blood collected after rh-EPO injections is an effective method for minimizing homologous blood transfusions in pulmonary and mediastinal surgery.

Topics: Blood Loss, Surgical; Blood Preservation; Blood Transfusion, Autologous; Blood Volume; Erythropoietin; Female; Humans; Lung Diseases; Male; Mediastinal Diseases; Middle Aged; Recombinant Proteins

To examine the influence of intra- and postoperative blood loss and operative trauma on erythropoietin (EPO) production we studied patients undergoing endoprosthetic surgery of the hip. Immunoreactive plasma EPO was determined in ten patients (seven male, three female, aged 39-68 years), undergoing surgery for hip arthroplasty (n = 8) or revision hip arthroplasty (n = 2). EPO levels had already been determined during preoperative autologous deposit, thus allowing direct comparison between EPO response to blood loss alone and the response to blood loss and operative trauma. Perioperative blood loss amounted to 1720 (480-8100) ml (median, range). The hemoglobin concentration decreased from 12.4 (10.6-14.0) g/dl (median, range) before the operation to 10.0 (9.3-12.3) g/dl 2 h after the operation. Thereafter, the hemoglobin concentration increased slowly due to transfusion and erythropoiesis and was not significantly different (p < 0.05) from the preoperative value on the seventh postoperative day. The EPO concentration was preoperatively 26 (11-28) mU/ml and increased 2 h after the end of the operation, reaching a peak of 64 (45-104) mU/ml at 24 h. This peak was followed by a plateau at lower, but still elevated levels. The EPO concentration remained significantly elevated above the preoperative value on the seventh postoperative day. Plasma EPO concentrations showed an adequate response to postoperative anemia compared with the time course after autologous donation. In the early postoperative phase, they do not seem to be appreciably influenced by the neuroendocrine response to trauma, by mediators of inflammation, or by the postoperative catabolic state. The slightly elevated EPO concentration in the late postoperative phase indicates that factors other than anemia may contribute to EPO production at this time.

Topics: Adult; Aged; Blood Loss, Surgical; C-Reactive Protein; Erythrocyte Count; Erythropoietin; Female; Fibrinogen; Hemoglobins; Hip Prosthesis; Humans; Kinetics; Male; Middle Aged; Reticulocytes

To examine the techniques and the outcome of liver transplantation with maximal conservation of blood products and to analyze the potential benefits or drawbacks of blood conservation and salvage techniques.. Case series survey.. Tertiary care, major university teaching hospital.. Four patients with religious objections to blood transfusions who were selected on the basis of restrictive criteria that would lower their risk for fatal hemorrhage, including coagulopathy, a thrombosed splanchnic venous system requiring extensive reconstruction, active bleeding and associated medical complications. All patients were pretreated with erythropoietin to increase production of red blood cells. All operations were performed at the same institution, with a 36-month follow-up.. Orthotopic liver transplantation that used blood salvage, plateletpheresis, and autotransfusion and the withholding of the use of human blood products with the exception of albumin.. Survival and postoperative complications, with the effectiveness of erythropoietin and plateletpheresis as secondary measures.. All patients are alive at 36 months after orthotopic liver transplantation. One patient, a minor (13 years of age), was transfused per a state court ruling. Erythropoietin increased the production of red blood cells as shown by a mean increase in hematocrit levels of 0.08. Platelet-pheresis allowed autologous, platelet-rich plasma to be available for use after allograft reperfusion. Three major complications were resolved or corrected without sequelae. Only one patient developed postoperative hemorrhage, which was corrected surgically. The mean charge for bloodless surgery was $174,000 for the three patients with United Network for Organ Sharing (UNOS) status 3 priority for transplantation. This result was statistically significant when these patients were compared with all the patients with UNOS status 3 priority during the same period who met the same restrictive guidelines (P < .05). Only 19 of 1009 orthotopic liver transplantations performed at our institution were similar according to the UNOS status and the fulfillment of the guidelines. The mean charge for these comparison patients was $327,000, 3.8% of which was related to transfusions.. Orthotopic liver transplantation without the use of blood products is possible. Blood conservation techniques do not increase morbidity or mortality and can result in fewer transfusion-related, in-hospital charges.

Topics: Adolescent; Adult; Blood Loss, Surgical; Christianity; Erythropoietin; Female; Follow-Up Studies; Hepatic Encephalopathy; Humans; Liver Transplantation; Male; Middle Aged; Plateletpheresis; Postoperative Complications; Preoperative Care; Reoperation; Time Factors

Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah's Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.

Topics: Adult; Ampulla of Vater; Blood Loss, Surgical; Blood Transfusion, Autologous; Christianity; Clinical Protocols; Common Bile Duct Neoplasms; Erythropoietin; Female; Hemoglobins; Humans; Intraoperative Care; Pancreaticoduodenectomy; Treatment Refusal

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Blood Loss, Surgical; Erythrocyte Count; Erythropoietin; Female; Humans; Male; Middle Aged; Time Factors

Topics: Adult; Antineoplastic Combined Chemotherapy Protocols; Blood Loss, Surgical; Blood Transfusion; Christianity; Combined Modality Therapy; Erythropoietin; Humans; Male; Mesonephroma; Recombinant Proteins

Topics: Adult; Aged; Anemia; Blood Loss, Surgical; Christianity; Erythropoietin; Female; Humans; Preoperative Care