Erythropoiesis, erythropoietin, and iron metabolism in elective surgery: preoperative strategies for avoiding allogeneic blood exposure

Application of an adjusted patient blood management protocol in patients undergoing elective total hip arthroplasty: towards a zero-percent transfusion rate in renal patients-results from an observational cohort study

BACKGROUND

Renal patients are at high risk of blood transfusion following major orthopaedic surgery. A variety of patient blood management (PBM) policies have been proposed to reduce the rate of transfusions. The aim of this observational study was to assess the performance of an adjusted PBM protocol in patients with chronic kidney disease (CKD) undergoing elective total hip arthroplasty (THA).

METHODS

A total of 1191 consecutive patients underwent elective unilateral THA and took part in an adjusted PBM protocol. The PBM protocol consisted of epoetin (EPO) alfa therapy prescribed by the surgeon, routine administration of tranexamic acid (TXA), an avascular approach to the hip and postoperative prophylaxis of thromboembolism. The performance of this PBM protocol was analysed in patients with a glomerular filtration rate (GFR) below or above 60 ml/min/1.73 m2 at baseline. Haemoglobin levels were controlled at admission, on postoperative day (POD) 1 and on POD 7 ± 1. A bleeding index (BI) was used as a proxy for blood loss.

RESULTS

In total, 153 patients (12.9%) presented with a modification of diet in renal disease value below 60 at baseline. Of these, 20 (13.1%) received EPO therapy and 120 (78.4%) received TXA. None of the patients received allogenic blood transfusions during the first perioperative week. The mean BI for the entire study population was 2.7 (95% CI 2.6, 2.8). CKD did not exert a significant impact on the BI (p = 0.287). However, it was found that both TXA and EPO therapy significantly lowered the BI (difference, - 0.3, p < 0.001). There were no thromboembolic complications in renal patients who received TXA and/or EPO therapy.

CONCLUSIONS

A zero-percent transfusion rate during the first perioperative week is attainable in patients with stage 3 or stage 4 CKD undergoing contemporary elective THA. With the use of a pragmatic blood-sparing protocol, patients with renal dysfunction did not have an increased risk of bleeding and did not have an increased incidence in the rate of perioperative blood transfusions.

Surgical prescription of epoetin alfa in contemporary total hip arthroplasty: a prospective comparative study

Purpose

Pre-operative anaemia treatment has been associated with reduced morbidity in joint arthroplasty. This study examined the impact of a surgical prescription of epoetin (EPO) in contemporary total hip arthroplasty (THA).

Methods

We conducted a comparative study in a series of 1402 primary THAs performed in patients all having a pre-operative haemoglobin (Hb) level documented four to eight  weeks before THA surgery. In group A (647 hips), one subcutaneous injection of 40,000 IU EPO once a week for four weeks was prescribed at the discretion of anaesthetist during the pre-operative visit in patients with pre-operative Hb between 10 and 13 g/dl. In group S comprising the remaining 755 hips, an amended EPO therapy including two  injections of 20,000 to 40,000 IU was prescribed by the surgeon in patients with Hb less than 12 g/dl deemed at high risks to be transfused following THA. Primary study endpoint was the bleeding index (BI).

Results

EPO therapy was delivered in 43 patients (6.7%) in group A and in 26 patients (3.4%) in group S (p = 0.006). The mean total dose of EPO administrated was 115,349 IU in group A versus 75,200 IU in group S (p < 0.001). The mean BI were 2.7 ± 1.0 in group A and 2.8 ± 1.0 g/dl in group S (p = 0.375). No patient was blood-transfused up to post-operative day seven in group S versus five patients in group A (p = 0.021).

Conclusions

The amended protocol does not lead to increased peri-operative bleeding. Advances in intra-operative methods to reduce the bleeding allow changing indications of EPO in patients undergoing THA with a low level of Hb.

A biomathematical model of human erythropoiesis under erythropoietin and chemotherapy administration

Anaemia is a common haematologic side effect of dose-dense multi-cycle cytotoxic polychemotherapy requiring erythrocyte transfusions or erythropoietin (EPO) administration. To simulate the effectiveness of different EPO application schedules, we performed both modelling of erythropoiesis under chemotherapy and pharmacokinetic and dynamic modelling of EPO applications in the framework of a single comprehensive biomathematical model. For this purpose, a cell kinetic model of bone marrow erythropoiesis was developed that is based on a set of differential compartment equations describing proliferation and maturation of erythropoietic cell stages. The system is regulated by several feedback loops comprising those mediated by EPO. We added a model of EPO absorption after injection at different sites and a pharmacokinetic model of EPO derivatives to account for the effects of external EPO applications. Chemotherapy is modelled by a transient depletion of bone marrow cell stages. Unknown model parameters were determined by fitting the predictions of the model to data sets of circulating erythrocytes, haemoglobin, haematocrit, percentage of reticulocytes or EPO serum concentrations derived from the literature or cooperating clinical study groups. Parameter fittings resulted in a good agreement of model and data. Depending on site of injection and derivative (Alfa, Beta, Delta, Darbepoetin), nine groups of EPO applications were distinguished differing in either absorption kinetics or pharmacokinetics. Finally, eight different chemotherapy protocols were modelled. The model was validated on the basis of scenarios not used for parameter fitting. Simulations were performed to analyze the impact of EPO applications on the risk of anaemia during chemotherapy. We conclude that we established a model of erythropoiesis under chemotherapy that explains a large set of time series data under EPO and chemotherapy applications. It allows predictions regarding yet untested EPO schedules. Prospective clinical studies are needed to validate model predictions and to explore the feasibility and effectiveness of the proposed schedules.

The effect of intravenous and oral iron administration on perioperative anaemia and transfusion requirements in patients undergoing elective cardiac surgery: a randomized clinical trial

OBJECTIVES

Anaemia is a frequent complication after cardiopulmonary bypass surgery. Iron therapy has been variably employed by medical centres over the years. In our study we test the clinical effectiveness of intravenous and oral iron supplementation in correcting anaemia, and its impact on blood transfusion requirements, in patients undergoing cardiopulmonary bypass surgery.

METHODS

A double-blind, randomized, placebo-controlled clinical trial with three parallel groups of patients. Group I (n = 54): intravenous iron(III)-hydroxide sucrose complex, three doses of 100 mg/24 h during pre- and postoperative hospitalization and 1 pill/24 h of oral placebo in the same period and during 1 month after discharge. Group II (n = 53): oral ferrous fumarate iron 1 pill/24 h pre- and postoperatively and during 1 month after discharge, and intravenous placebo while hospitalized. Group III (n = 52): oral and intravenous placebo pre- and postoperatively, following the same protocol. Data were collected preoperatively, at theatre, at intensive care unit admission, before hospital discharge and 1 month later.

RESULTS

(1) Baseline clinical and demographic characteristics and surgical procedures were similar in the three groups; (2) no inter-group differences were found in haemoglobin and haematocrit during the postoperative period; (3) the intravenous iron group showed higher serum ferritin levels at hospital discharge (1321 ± 495 ng/ml; P < 0.001) and 1 month later (610 ± 387; P < 0.001) compared with the other groups and (4) we did not observe statistical differences in blood transfusion requirements between the three groups.

CONCLUSIONS

The use of intravenous or oral iron supplementation proved ineffective in correcting anaemia after cardiopulmonary bypass and did not reduce blood transfusion requirements. [Current Controlled Trials number: NCT01078818 (oral and intravenous iron in patients postoperative cardiovascular surgery under EC)].

The Use of Soluble Transferrin Receptor in the Detection of rHuEPO abuse in Sports

Erythropoietin (EPO) increases the number of circulating erythrocytes and muscle oxygenation. The recombinant forms of EPO have indiscriminately been used by athletes, mainly in endurance sports to increase their erythrocytes concentration, thus generating a better delivery of oxygen to the muscle tissue. The administration of recombinant human erythropoietin (rHuEPO) except for therapeutic use was prohibited by the International Olympic Committee (IOC) and its unauthorized use considered as doping. In the last few years, a number of studies using parameters indicative of accelerated erythropoiesis have investigated a number of indirect methods for the detection of rHuEPO abuse. No single indirect marker has been found that can satisfactorily demonstrated rHuEPO misuse. Soluble transferrin receptor (sTfR) is a new marker of iron status and erythropoietic activity. It has been included in multivariable blood testing models for the detection of performance enhancing EPO abuse in sports. Indirect markers of altered erythropoiesis give reliable evidence of current or discontinued rHuEPO usage. This review describes the physical, biological and pharmacokinetic properties of endogenous EPO and its recombinant form. It also discusses the available strategies for the detection of rHuEPO abuse in sports, involving the use of sTfR concentration directly or in mathematical multivariate models.

Clinical impact of blood storage lesions

Recent reports suggest that transfusion of old red blood cell (RBC) units (>2 weeks) was associated with increased risks of postoperative complications and higher mortality rate caught public attention (Yap et al., Ann Thorac Surg 2008; 86:554-559 and Koch et al., 2008; 358:1229-1239). This rekindled the decades old discussion regarding the impact of RBC aging and storage lesions in patient care. The objectives of this review are to provide readers with an overview of the process of banking RBC that may have an impact on its quality, the reported clinical impact of storage lesions, the consequences of transfusing new RBC units only to the nation's blood supply and potential solutions that may improve the feasibility of blood banks to issue new blood units only.

The role of erythropoietin in the acute phase of trauma management: evidence today

Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.

A cluster-randomized controlled trial of a blood conservation algorithm in patients undergoing total hip joint arthroplasty

BACKGROUND

The optimum strategy for reducing allogeneic blood transfusion in patients undergoing total hip joint arthroplasty (THJA) is unknown.

STUDY DESIGN AND METHODS

The effectiveness of a comprehensive blood conservation algorithm (BCA) was evaluated by means of a cluster randomization trial. Thirty hospitals performing primary THJA were randomly assigned to implement the algorithm or to continue with usual care (UC). Subsequently, the institutional rate of allogeneic transfusion was determined for 60 consecutive patients who underwent surgery at each site. The BCA consisted of patient and provider education, hemoglobin-based recommendations for specific blood conservation strategies (recombinant human erythropoietin [rHuEPO] or autologous blood donation [ABD]) and transfusion guidelines. The main outcome measure was the institutional allogeneic transfusion rate.

RESULTS

One hospital withdrew consent after randomization, resulting in 14 hospitals assigned to BCA and 15 to UC. In the BCA arm, the institutional rates of rHuEPO use and ABD participation were 20.1 and 27.1 percent compared to 0.6 and 25.8 percent, respectively, in the UC arm. The allogeneic transfusion rate was substantially reduced in hospitals assigned to the BCA group (p = 0.02; absolute risk reduction, 9.6% [26.1% UC vs. 16.5% BCA]). Multivariate analysis of patient-level data showed that assignment to the UC arm was an independent risk factor for allogeneic transfusion (p = 0.037; odds ratio, 1.8; 95% confidence interval, 1.0-3.1) when adjusted for other prognostic factors. No differences were observed in the use of autologous blood.

CONCLUSION

A comprehensive approach to blood conservation was superior to UC for reducing allogeneic transfusion in patients undergoing THJA.

Blood sparing in craniosynostosis surgery

One of the main risks of craniosynostosis surgery is the possible need for an allogenic blood transfusion (ABT). Most patients are operated on in the first months of life, when physiological conditions are particularly sensitive to even limited blood losses. Furthermore, most surgical techniques proposed in the past were based on extensive craniectomies and cranial remodeling. Because of the known infective and immunologic risks of ABT, in recent years more attention has been dedicated to factors that might help reduce the risk of ABT. We review recent preoperative (ie, erythropoietin administration), intraoperative (ie, acute normovolemic hemodilution, intraoperative blood salvage), and postoperative (ie, clinical monitoring, postoperative blood salvage) anesthesiologic procedures developed with this aim in mind. We also consider operative techniques and technical apparatus that reduce surgical invasiveness, particularly preoperative planning, age selection, and the role of endoscopic assistance and gradual distraction devices.

Preoperative erythropoietin in spine surgery

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.

CONCLUSIONS

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.

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application

OBJECTIVE

Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients.

SUMMARY BACKGROUND DATA

Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients.

METHODS

From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed.

RESULTS

Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients.

CONCLUSIONS

Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.

Postoperative intravenous iron used alone or in combination with low-dose erythropoietin is not effective for correction of anemia after cardiac surgery

OBJECTIVES

The aim of this study was to examine whether intravenous iron III-hydroxide sucrose complex (IHSC) used alone was sufficient to provide rapid correction of anemia after cardiac surgery and whether additional stimulation of erythropoiesis is possible by means of a single low dose of recombinant-human erythropoietin (r-HuEPO) administration.

DESIGN

Prospective, randomized, double-blind study.

SETTING

The study was conducted in a university hospital.

PARTICIPANTS

One hundred twenty American Society of Anesthesiologists II or III patients, who underwent elective cardiac surgery using cardiopulmonary bypass and in whom postpump hemoglobin ranged between 7 and 10 g/dL.

INTERVENTIONS

Patients were divided into 3 groups: group I = control; group II received postoperative intravenous iron supplementation with an iron III-hydroxide sucrose complex (IHSC); and group III received IV iron and a single dose of r-HuEPO (300 U/kg).

MEASUREMENTS AND RESULTS

No significant difference in transfusion needs was observed among the 3 groups (22%, 25%, and 17% of patients transfused in groups I, II, and III, respectively). Hemoglobin levels, reticulocyte counts, and serum ferritin levels were evaluated at different time intervals (until day 30 postoperatively). No side effects because of iron administration were noted in the study. Reticulocyte counts increased rapidly at day 5 (2.24% +/- 1.11%, 1.99% +/- 1.44%, and 3.84% +/- 2.02% in groups I, II, and III, respectively) and decreased after day 15 in the 3 groups. Ferritin levels increased significantly at day 5 in the 2 treated groups (899.33 +/- 321.55 ng/mL in group II, 845.75 +/- 289.96 ng/mL in group III v 463.15 +/- 227.74 ng/mL in group I). In group I, ferritin levels, after a slight elevation on day 5, decreased at day 15 to lower than baseline levels. No significant difference in hemoglobin increase was noted among the 3 groups.

CONCLUSION

Postoperative intravenous iron supplementation alone or in combination with a single dose of r-HuEPO (300 U/kg) is not effective in correcting anemia after cardiac surgery.

Perioperative erythropoietin administration in patients with gastrointestinal tract cancer: prospective randomized double-blind study

OBJECTIVE

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.

SUMMARY BACKGROUND DATA

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Increased serum erythropoietin concentration after allogeneic compared with autologous blood transfusion

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.

Perioperative use of erythropoietin

Erythropoietin (EPO) is the primary regulator of red blood cell (RBC) production, and hypoxia is the main stimulus for EPO secretion. Increases in circulating levels of EPO are proportionate to the levels of tissue hypoxia, which are influenced by hematocrit (HCT). Small decreases in HCT as would be typical after presurgical autologous blood donation often do not result in increased EPO levels or in compensatory erythropoiesis. Erythropoiesis may also be limited by deficiencies of vitamin B(12), folate, and, most commonly, iron. The preoperative administration of EPO is effective in increasing erythrocyte mass and autologous donation volumes while maintaining higher HCT levels. In some surgical populations, particularly those individuals who experience surgical blood losses in excess of 2 L, EPO treatment also reduces allogeneic blood exposure. This effect is prominent in patients with a low initial HCT. Current assessments of the cost-effectiveness of EPO suggest that it achieves little overall improvement in patient health and that what improvement it does offer, it does at enormous cost.

Role of oral versus IV iron supplementation in the erythropoietic response to rHuEPO: a randomized, placebo-controlled trial

BACKGROUND

Preoperative treatment with rHuEPO (epoetin alfa: EPREX, Janssen-Cilag; or PROCRIT, Ortho Biotech) in conjunction with iron supplementation increases the erythropoietic response in elective orthopedic surgery patients, but it is not known whether the magnitude of this response is dependent on the route of iron administration.

STUDY DESIGN AND METHODS

Non-iron-deficient patients undergoing elective orthopedic surgery (N = 110) with baseline Hb > or =10 to < or =13 g per dL were randomly assigned to receive either epoetin alfa (600 IU/kg) plus IV iron (n = 29) or oral iron (n = 29) or placebo plus IV iron (n = 25) or oral iron (n = 27) in this 14-day study. RBC production, Hb, Hct, reticulocytes, iron status, and adverse events were monitored throughout the study.

RESULTS

Epoetin alfa treatment plus either oral or IV iron supplementation significantly increased total RBC production, Hb, Hct, and reticulocytes over the values seen with the respective placebo treatments (p = 0.0001). There were no differences between the epoetin alfa treatment groups. Placebo treatment plus oral or IV iron supplementation was not associated with increases in hematologic values. There were no differences in the incidence of adverse events among the treatment groups.

CONCLUSION

There was a comparable erythropoietic response to epoetin alfa, irrespective of the route of iron administration. The route of iron administration, therefore, does not modulate the erythropoietic response to epoetin alfa in patients who are not iron deficient. Safety and convenience benefits may be gained by adopting oral iron supplementation in this patient subset.

Preoperative predictors of the need for allogeneic blood transfusion in lung cancer surgery

BACKGROUND

The use of blood-saving techniques in elective surgery can produce a favorable cost-benefit ratio only when there is a reasonable likelihood that transfusion will be required. To apply a targeted blood-sparing technique in lung cancer surgery, the patient's preoperative characteristics that predict the use of allogeneic blood transfusion (ABT) in this practice were investigated.

STUDY DESIGN AND METHODS

One hundred seventy-three consecutive patients who underwent primary lung cancer surgery were included in this retrospective study. Clinical and epidemiologic variables, lung tumor extension (TNM staging), and surgery type were analyzed by logistic regression to discover the preoperative predictors of ABT.

RESULTS

Thirty patients, 17.3 percent of all who underwent surgery and 19.9 percent of those who underwent resolvent surgery, received ABT. Excluding a patient who needed 18 units of RBCs, the number of ABT units required by transfused patients was 1. 93 +/- 0.88 (mean +/- SD). Extensive surgery, patient's age (< or =64 years), and elevated erythrocyte sedimentation rate (>45 mm/hour) were the preoperative variables that influenced the need for ABT. The definitive predictive model was able to recognize 82.3 percent of patients who received ABT and 95.6 percent of those who did not.

CONCLUSION

A predictive model can preoperatively identify patients at risk for needing ABT in lung cancer surgery. The model could be utilized to tailor blood-sparing intervention programs.

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

OBJECTIVE

To determine the safety and effectiveness of blood donation in anemic patients, we harvested blood from cardiac patients with baseline hemoglobin levels below 11.0 g/dl.

METHODS

Subjects were 118 patients who underwent elective cardiac surgery between January 1994 and October 1997. We assigned patients to 1 of 2 groups based on their entry hemoglobin level: an anemic group (hemoglobin < 11.0 g/dl, n = 20) and a nonanemic group (hemoglobin > or = 11.0 g/dl, n = 98). All patients received subcutaneous administration of recombinant human erythropoietin, and autologous blood was collected once a week for at least 3 weeks before the scheduled surgery date if the hemoglobin level exceeded 10.5 g/dl.

RESULTS

No statistically significant differences were seen between the 2 groups in patient profiles or surgical data. The estimated hemoglobin increase did not differ significantly between groups at any time point. The total collected blood volume per patient was greater in the nonanemic group than in the anemic group (1098 +/- 224 ml vs. 712 +/- 334 ml), but the difference in volume was not statistically significant. The percentage of patients who received allogeneic blood did not differ significantly between groups. No side effects were associated with hemoglobin level prior to donation because the incidence of side effects was similar across hemoglobin levels.

CONCLUSIONS

This study suggests that autologous blood donation reduces the need for allogeneic blood in patients with baseline hemoglobin levels below 11.0 g/dl.

Autologous blood donation with recombinant human erythropoietin in anemic patients

BACKGROUND

Various blood management strategies can be used to reduce the need for allogeneic blood in cardiac surgery. In anemic patients, however, avoidance of allogeneic blood transfusion is difficult to achieve. This study was performed to assess the safety and effectiveness of preoperative blood collection using recombinant human erythropoietin (rHuEPO) for reducing the exposure to allogeneic blood in anemic patients.

METHODS

Thirty-two anemic patients undergoing cardiac surgery at our hospital between January 1994 and October 1997 were divided into two groups according to preoperative strategies: 3-week treatment with rHuEPO and blood donation (group 1, n = 16) or iron supplementation alone (group 2, n = 16).

RESULTS

There were no statistically significant differences between the two groups in patients' characteristics and surgical data. The number of reticulocytes was increased at just before surgery in group 1, whereas group 2 showed no significant increase. The estimated hemoglobin increases in group 1 were higher at 7 days and just before surgery. The mean number of required allogeneic blood for patients during surgery was 0.59 +/- 1.12 U in group 1 and 5.01 +/- 2.63 U in group 2. In 75% of group 1 patients, allogeneic blood transfusion was successfully avoided, whereas all patients in group 2 received allogeneic blood.

CONCLUSIONS

This study suggests that the combination of rHuEPO administration and autologous blood donation can reduce the need for allogeneic blood in anemic patients.

Transfusion-free surgery is a treatment plan for all patients

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.

Diagnosis and management of placenta percreta: a review

A review of the clinical decisions, diagnostic, and surgical methods in managing patients with placenta percreta was done by conducting a MEDLINE computerized search from January 1991 to January 1997 using the key words "placenta percreta," "placenta previa," "acute normovolemic hemodilution," and "erythropoietin use." Additional sources were identified through cross-referencing. We reviewed all published reports and articles regarding the clinical and surgical management of placenta percreta and nontraditional ways to treat or prevent anemia in these cases (including acute normovolemic hemodilution and erythropoietin use). The diagnosis of placenta percreta using different ultrasonographic criteria is reliable. Clinical and surgical methods of managing placenta previa with a high risk of percreta are all based on prevention of uncontrolled hemorrhage. Ninety percent of these patients will lose more than 3000 ml intraoperatively and will require blood transfusion. To avoid serious maternal morbidity secondary to hypovolemia, several options are available: erythropoietin use, acute normovolemic hemodilution, selective arterial embolization, prophylactic uterine, or hypogastric artery ligation. With the increasing incidence of placenta percreta, the clinician must use all available methods to accurately diagnose this condition. Adequate preparation and good surgical technique will help reduce maternal mortality and morbidity related to this condition.

Use of Erythropoietin in the Severely Anemic Jehovah's Witness Patient: Case Report and Review of the Literature

Objective:

To describe and discuss the use of erythropoietin as a therapeutic option for treatment of severe anemia in a patient whose religious beliefs preclude the use of blood products.

Case Summary:

A 23-year-old male Jehovah's Witness patient presented to the emergency department with multiple fractures and significant blood loss secondary to trauma experienced in a motor vehicle accident. The patient refused transfusion because of his religious beliefs. He was given oxygen and lactated Ringer's solution, and phlebotomy was kept to a minimum. Erythropoietin was recommended to increase production of red blood cells. Review of the product information revealed that all available erythropoietin products contain human albumin as a stabilizer. After discussion with the clinical pharmacist, the patient and his family agreed to the use of erythropoietin. The patient's hematocrit and hemoglobin improved sufficiently for him to be taken to surgery on hospital day 12, and on hospital day 23 he was discharged.

Discussion:

Because Jehovah's Witnesses refuse to receive blood products, alternative methods for treatment of severe anemia must be used. Although some options are clearly unacceptable, certain volume expanders can be used in conjunction with oxygen and intravenous or oral iron that do not violate the patient's religious convictions. Erythropoietin is acceptable to most Jehovah's Witnesses; however, it contains human album (2.5 mg/mL), which may be of concern to some of these patients.

Conclusions:

Effective communication with the patient and the patient's family regarding all treatment options is required for treatment of severe anemia in the Jehovah's Witness patient. Erythropoietin, in conjunction with iron, adequate oxygenation, and good nutritional support, sometimes is an acceptable alternative in Jehovah's Witnesses.