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Alternatives to allogeneic blood transfusions

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Inherent risks and increasing costs of allogeneic transfusions underline the socioeconomic relevance of safe and effective alternatives to banked blood. The safety limits of a restrictive transfusion policy are given by a patient's individual tolerance of acute normovolaemic anaemia. Iatrogenic attempts to increase tolerance of anaemia are helpful in avoiding premature blood transfusions while at the same time maintaining adequate tissue oxygenation. Autologous transfusion techniques include preoperative autologous blood donation (PAD), acute normovolaemic haemodilution (ANH), and intraoperative cell salvage (ICS). The efficacy of PAD and ANH can be augmented by supplemental iron and/or erythropoietin. PAD is only cost-effective when based on a meticulous donation/transfusion plan calculated for the individual patient, and still carries the risk of mistransfusion (clerical error). In contrast, ANH has almost no risks and is more cost-effective. A significant reduction in allogeneic blood transfusions can also be achieved by ICS. Currently, some controversy regarding contraindications of ICS needs to be resolved. Artificial oxygen carriers based on perfluorocarbon (PFC) or haemoglobin (haemoglobin-based oxygen carriers, HBOCs) are attractive alternatives to allogeneic red blood cells. Nevertheless, to date no artificial oxygen carrier is available for routine clinical use, and further studies are needed to show the safety and efficacy of these substances.

Section snippets

Tolerance of acute normovolaemic anaemia

The initial treatment of intraoperative blood loss always consists in the maintenance of normovolaemia by the infusion of crystalloid (3:1) and colloidal solutions (1:1). This acellular fluid replacement implies the dilution of the cell mass remaining in the vasculature (haemodilution), resulting in a dilutional anaemia (acute normovolaemic anaemia).

In the context of alternatives to allogeneic blood transfusion, the term ‘anaemia tolerance’ is used to refer to the patient's physiological

Autologous transfusion techniques

Autologous transfusion techniques are generally intended to replace as many allogeneic RBC transfusions as possible by (re)transfusion of autologous blood. Autologous blood is either harvested a couple of weeks before (preoperative blood donation, PAD) or immediately before surgery (acute normovolaemic haemodilution, ANH). The concept of intraoperative cell salvage (ICS) implies the collection and reprocessing of shed blood for autologous retransfusion.

Artificial oxygen carriers

An attractive alternative to allogeneic RBCs consists in synthetic blood substitutes (artificial oxygen carriers), which can be applied independently of blood-group typing or infectious risks. Currently, there are two types of artificial oxygen carrier under experimental and clinical investigation: (1) synthetically manufactured perfluorocarbons (PFC), and (2) haemoglobin-based oxygen carriers (HBOCs), i.e., solutions based on isolated human or bovine haemoglobin.61

References (101)

  • E.E. Moore

    Blood substitutes: the future is now

    Journal of the American College of Surgeons

    (2003)
  • D. Nolte et al.

    Effects of diaspirin-cross-linked hemoglobin (DCLHb) on local tissue oxygen tension in striated skin muscle: an efficacy study in the hamster

    The Journal of Laboratory and Clinical Medicine

    (1997)
  • S.A. Gould et al.

    The life-sustaining capacity of human polymerized hemoglobin when red cells might be unavailable

    Journal of the American College of Surgeons

    (2002)
  • D.C. Cheng et al.

    A phase II dose-response study of hemoglobin raffimer (Hemolink) in elective coronary artery bypass surgery

    The Journal of Thoracic and Cardiovascular Surgery

    (2004)
  • A.G. Greenburg et al.

    Use of an oxygen therapeutic as an adjunct to intraoperative autologous donation to reduce transfusion requirements in patients undergoing coronary artery bypass graft surgery

    Journal of the American College of Surgeons

    (2004)
  • M.A. Garrioch et al.

    Haemodynamic effects of diaspirin crosslinked haemoglobin (DCLHb) given before abdominal aortic aneurysm surgery

    British Journal of Anaesthesia

    (1999)
  • J.K. Hayes et al.

    A double-blind study to evaluate the safety of recombinant human hemoglobin in surgical patients during general anesthesia

    Journal of Cardiothoracic and Vascular Anesthesia

    (2001)
  • G.I. Kemming et al.

    Hyperoxic ventilation at the critical haematocrit

    Resuscitation

    (2003)
  • L.T. Goodnough

    Risks of blood transfusion

    Critical Care Medicine

    (2003)
  • C. Madjdpour et al.

    Risks, benefits, alternatives and indications of allogenic blood transfusions

    Minerva Anestesiologica

    (2006)
  • P.C. Hebert et al.

    A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

    The New England Journal of Medicine

    (1999)
  • J.L. Vincent et al.

    Anemia and blood transfusion in critically ill patients

    JAMA: The Journal of the American Medical Association

    (2002)
  • H.L. Corwin et al.

    The CRIT Study: Anemia and blood transfusion in the critically ill–current clinical practice in the United States

    Critical Care Medicine

    (2004)
  • R.W. Taylor et al.

    Red blood cell transfusions and nosocomial infections in critically ill patients

    Critical Care Medicine

    (2006)
  • T.L. Palmieri et al.

    Effect of blood transfusion on outcome after major burn injury: a multicenter study

    Critical Care Medicine

    (2006)
  • S.J. Varney et al.

    The annual cost of blood transfusions in the UK

    Transfusion Medicine (Oxford, England)

    (2003)
  • K.F. Messmer

    Acceptable hematocrit levels in surgical patients

    World Journal of Surgery

    (1987)
  • D.R. Spahn et al.

    Eliminating blood transfusions: new aspects and perspectives

    Anesthesiology

    (2000)
  • S.M. Cain

    Oxygen delivery and uptake in dogs during anemic and hypoxic hypoxia

    Journal of Applied Physiology

    (1977)
  • J.M. Meier et al.

    Hyperoxic ventilation reduces 6-hour mortality at the critical hemoglobin concentration

    Anesthesiology

    (2004)
  • J.L. Fontana et al.

    Oxygen consumption and cardiovascular function in children during profound intraoperative normovolemic hemodilution

    Anesthesia and Analgesia

    (1995)
  • A. Zollinger et al.

    Extreme hemodilution due to massive blood loss in tumor surgery

    Anesthesiology

    (1997)
  • R.L. van Citters et al.

    Cardiovascular performance of Alaska sled dogs during exercise

    Circulation Research

    (1969)
  • C. Madjdpour et al.

    Anemia and perioperative red blood cell transfusion: a matter of tolerance

    Critical Care Medicine

    (2006)
  • P. van der Linden et al.

    Tolerance to acute isovolemic hemodilution. Effect of anesthetic depth

    Anesthesiology

    (2003)
  • D.D. Vernon et al.

    Effect of neuromuscular blockade on oxygen consumption and energy expenditure in sedated, mechanically ventilated children

    Critical Care Medicine

    (2000)
  • V. Perez-de-Sa et al.

    Mild hypothermia has minimal effects on the tolerance to severe progressive normovolemic anemia in Swine

    Anesthesiology

    (2002)
  • O.P. Habler et al.

    Hyperoxaemia in extreme haemodilution

    British Journal of Anaesthesia

    (1998)
  • A. Pape et al.

    Hyperoxic ventilation increases the tolerance of acute normovolemic anemia in anesthetized pigs

    Critical Care Medicine

    (2006)
  • O.P. Habler et al.

    Hemodilution and intravenous perflubron emulsion as an alternative to blood transfusion: effects on tissue oxygenation during profound hemodilution in anesthetized dogs

    Transfusion

    (1998)
  • O.P. Habler et al.

    Effects of hyperoxic ventilation on hemodilution-induced changes in anesthetized dogs

    Transfusion

    (1998)
  • O. Habler

    Cardiac high-risk patients: From ‘permissive’ to ‘deliberate’ anemia

    Critical Care Medicine

    (2005)
  • B.A. Rogers et al.

    Audit on the efficient use of cross-matched blood in elective total hip and total knee replacement

    Annals of the Royal College of Surgeons of England

    (2006)
  • B. Hutton et al.

    Transfusion rates vary significantly amongst Canadian medical centres

    Canadian Journal of Anaesthesia

    (2005)
  • E.M. Keating et al.

    Perioperative blood management practices in elective orthopaedic surgery

    The Journal of the American Academy of Orthopaedic Surgeons

    (2002)
  • O.P. Habler et al.

    Verfahren zur Reduktion von Fremdblut in der operativen Medizin

    Anaesthesist

    (1997)
  • A. Shander

    Surgery without blood

    Critical Care Medicine

    (2003)
  • P. Carless et al.

    Autologous transfusion techniques: a systematic review of their efficacy

    Transfusion Medicine (Oxford, England)

    (2004)
  • K. Messmer et al.

    Hemodilution

    Progress in Surgery

    (1974)
  • D. Murray

    Acute normovolemic hemodilution

    European Spine Journal

    (2004)
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