Hemodilution in clinical surgery: state of the art 1996

Acute normovolemic hemodilution entails removal of blood from a patient either immediately before or shortly after induction of anesthesia and simultaneous replacement with cell-free fluid. Nowadays, because of their predictable volume effects, the synthetic colloids (6% dextran 60/70, 6% hydroxyethyl starch 200,000) are preferred as volume substitutes; albumin should be avoided because of its high cost. Hemodilution has experienced a renaissance in recent years, mainly due to the evolving discussion of legal aspects, immunologic changes, viral infections, and a potentially higher cancer recurrence rate associated with the transfusion of homologous blood. Hemodilution should be considered for elective surgical patients free of contraindications and presenting with an initial hemoglobin concentration >/= 12 g/dl and an anticipated blood loss of >/= 1500 ml. The efficacy of this method (judged by the need to give homologous blood transfusion) depends on the preoperative (initial) hematocrit, the target hematocrit (to which hemodilution is performed), and the preset intra- and postoperative transfusion trigger. In the past, data from clinical trials showed that in healthy subjects a target hematocrit of 20% to 25% (hemoglobin 7.0-8. 0 g/dl) is feasible and safe for the patient. The lower the target hematocrit accepted, the more extensive is the monitoring required: Intraoperative target hemoglobin concentrations of 5.0 g/dl and less have been tolerated by surgical patients without adverse effects. The safety and efficacy of acute normovolemic hemodilution in terms of reducing homologous blood transfusion requirements has been demonstrated in various clinical studies. Hemodilution therefore is regarded an integral part of programs aimed at reducing the need for homologous blood and can thus be successfully combined with preoperative autologous blood deposition, intraoperative blood salvage, and carefully adjusted surgical techniques. Hemodilution is feasible and relatively cost-effective, and it minimizes adverse effects associated with transfusion of homologous blood, particularly transmission of viral diseases, immunosuppression, and infectious complications.     

Preoperative autologous blood donation in patients with malignant tumors of the head and neck region

Twelve instances of preoperative autologous blood donation were assessed in 10 patients with malignant tumors of the head and neck region. All patients received preoperative radiation therapy and chemotherapy and most of the cases were also given recombinant human erythropoietin (EPO) and iron sulfate. Hemoglobin concentrations immediately before starting the 800ml blood donations were higher than 13g/dl in 5 cases and less than 13g/dl in 6 cases. The mean hemoglobin concentration just prior to donation and one week after donation in these two groups changed from 14.4g/dl to 12.5g/dl and 11.7g/dl to 11.7g/dl, respectively. A 1000ml blood donation was carried out in only one patient, and the hemoglobin concentrations just before donation and one week after donation were 11.4g/dl and 10.5g/dl, respectively. Only half of the blood volume scheduled, 400ml, was achieved in 3 of the 12 cases attempted because of fever, diarrhea and a change of the day of surgery, respectively. The mean estimated blood loss in the 10 patients that underwent surgery as planned was 898ml, and allogenic blood transfusion was avoided in all cases. We concluded that 800-1000ml preoperative autologous blood donation can be performed safely in patients with advanced malignant tumors of the head and neck region who have undergone preoperative radiation therapy and chemotherapy by giving EPO and iron sulfate.     

Laparoscopic splenectomy in a Jehovah's Witness with profound anemia

Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion.     

Intraoperative aspiration and reinfusion of autologous blood in resection of abdominal aortic aneurysms with Solcotrans plus

Quantitative and qualitative assessment of intraoperative aspiration and reinfusion of autologous blood with the Solcotrans was carried out in 11 males (52-79 years) undergoing elective resection of abdominal aortic aneurysms. Hematology, blood chemistry, coagulation parameters and complement activation were studied in the patient's blood at the following time points: preoperatively, before and after heparinisation, after retransfusion of the first and last Solcotrans, 6 and 20 hours postoperatively. In addition the same quality control was performed in the first and last Solcotrans blood. Results (mean values of 11 patients +/- 1 SD): Intraoperatively 2-3 Solcotrans units were salvaged (total 1039 +/- 565 ml) of which 805 +/- 487 ml were retransfused to the patients. As a mean patients required only 1 unit of homologous RBC's (395 +/- 781 ml) intraoperatively. Patient's intraoperative hemoglobin concentration amounted to 10 g/dl or more. Whereas the hemoglobin level in the Solcotrans attained only 8.2 g/dl. Thrombocyte counts (48 +/- 18 x 10(9)/l) and ionized calcium (0.2 +/- 0.4 mmol/l) were significantly depressed when compared to the preoperative patient values (p < 0.05). The protein concentration remained within normal limits in the patient's and in the Solcotrans blood. Complement activation (C4a, C5a [des Arg]) showed a significant increase after initiation of surgery and there was no significant difference between the solco- or patient blood. Whereas plasma free hemoglobin, coagulation and fibrinolysis parameters showed a significant elevation in the Solcotrans blood. In conclusion the solcotrans system offers a fast, efficient and simple method for salvage and retransfusion of intraoperative autologous blood.     

Open heart surgery in a Jehovah's Witness boy--a case report of successful management of aortic regurgatation and aneurysm of sinus Valsalva due to infective endocarditis

Jehovah's Witness who require operation represent a challenge to the physician because of the patients' refusal to accept blood transfusion. We report an 8-year-old male of Jehovah's Witness who underwent a surgical treatment of infective endocarditis. He was transferred to our hospital because of high fever and heart murmur. Echocardiogram revealed a developing vegetation of aortic cusps and an aneurysmal change of the non-coronary sinus Valsalva. On admission he was complicated by anemia, purulent meningitis and suppurative arthritis of left knee. There were no signs of cardiac failure. Erythropoietin (6000 U thrice weekly) and iron (60 mg daily) were given for 11 weeks prior to surgery, raising the hemoglobin level from 9.2 g/dl to 18.4 g/dl. Aortic valve replacement and plasty of the sinus Valsalva were then performed. Intraoperatively hemoglobin concentration dropped to 10.3 g/dl and it raised to 15 g/dl postoperatively. We also used Cell-Saver to reduce blood loss. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case.     

The effect of intermittent pneumatic compression devices on intraoperative blood loss during radical prostatectomy and radical cystectomy

Intermittent pneumatic compression devices are a widely used, effective and presumed risk-free method of deep venous thrombosis prophylaxis, presumably by increasing peak venous blood velocity, and stimulating local and systemic fibrinolysis. We investigated whether intermittent pneumatic compression devices had any effect on intraoperative blood loss or transfusion during radical pelvic urological surgery. To our knowledge no previous study has addressed these issues. Records were reviewed for patients undergoing radical retropubic prostatectomy or radical cystectomy with diversion from 1985 to 1990. A total of 91 cases was reviewed: 38 radical retropubic prostatectomies and 53 radical cystectomies with diversion (34 male and 19 female patients). There were 59 patients with intermittent pneumatic compression devices (29 radical retropubic prostatectomies and 30 radical cystectomies with diversion) and 32 without intermittent pneumatic compression devices (9 radical retropubic prostatectomies and 23 radical cystectomies with diversion). Intraoperative blood loss and transfusions were calculated for each group with and without intermittent pneumatic compression devices. No clinically apparent lower extremity deep venous thrombosis or pulmonary embolus was diagnosed in any patient. For the group with intermittent pneumatic compression devices mean intraoperative blood loss was 2,541 ml. (range 700 to 8,850) versus 1,807 ml. (range 450 to 5,100) without a device, for a statistically significant difference of 734 ml. (p = 0.005). When 5 patients with excessive intraoperative blood loss (more than 5,000 ml.) were excluded the statistically significant difference was maintained. When comparing radical retropubic prostatectomy and radical cystectomy with diversion, with and without intermittent pneumatic compression devices, blood loss was greater for the group with a device for each procedure. Differences in intraoperative blood loss were independent of sex or tumor stage. Intraoperative transfusions were increased by approximately 0.6 units per patient with the device. Our study suggests that intermittent pneumatic compression devices may increase blood loss during a radical pelvic operation.     

Hemodilution with other blood reinfusion techniques in total hip arthroplasty

Acute normovolemic hemodilution has been reported to result in blood savings varying from 18% to 90%. Very few of these are randomized prospective studies. This study attempts to determine the blood transfusion savings if acute normovolemic hemodilution is used in combination with autologous predonated blood and cell saver. Thirty-three patients undergoing total hip arthroplasty were assigned randomly to one of two groups (control, n = 16; hemodilution, n = 17). Patients in both groups entered an autologous predonation program if cleared medically and were placed on Cell Saver intraoperatively and in the postanesthesia care unit. In addition, the hemodilution group underwent acute normovolemic hemodilution preoperatively. Only 41% of the patients in the hemodilution group required any autologous blood transfusion as compared with 75% of the control group. In addition, the hemodilution group required a mean lower quantity of autologous blood transfusion (41% of the estimated blood loss) as compared with the control group (71%). The net anesthesia time increased by an average of 11.4 minutes in the hemodilution group. Acute normovolemic hemodilution is a safe procedure even in an older patient population. Hemodilution resulted in fewer patients needing autologous predonated blood transfusions. The major benefit of hemodilution was seen when predonation was not possible.     

Anti-ulcerogenic activity of GABA and GABA mimetic agents in rats

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. METHODS AND RESULTS: 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. CONCLUSIONS: 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.     

Perioperative specific management of blood volume loss in craniosynostosis surgery

Accurate assessment and replacement of blood loss and fluid-electrolyte deficit during craniosynostosis repair is difficult owing to patient size and the diversity of surgical technique. Forty-three patients undergoing primary craniosynostosis repair over a 10-year period were studied retrospectively to determine blood loss and fluid deficit and to assess blood transfusion practices during both intraoperative and postoperative periods. Blood loss was calculated on the basis of estimated red cell mass (ERCM) and fluid-electrolyte imbalance was investigated with blood samplings. Blood transfusion was considered appropriate if the postoperative or posttransfusion ERCM was within 12% of the preoperative value. Estimated fluid requirement (EFR) was used in 4 ml kg(-1) h(-1) except for neonates. Intraoperatively, 80% of all patients were appropriately managed with respect to blood transfusion and EFR. Postoperatively only 20% of the patients receiving transfusions were transfused appropriately. In 23.3% of these patients (10/43) unexpected respiratory distress developed immediately after their recovery from the anesthesia. With the measurement of estimated blood volume and allowable blood loss, appropriate transfusion could be achieved for the successful treatment of the primary craniosynostosis.     

"No allogeneic blood transfusion" protocol for the surgical correction of craniosynostoses. II. Clinical application

The authors describe the results obtained in 13 consecutive cases of craniosynostosis operated on according to a protocol devised at avoiding allogeneic blood transfusion. The protocol is based on pre- and postoperative treatment with erythropoietin, preoperative autologous blood donation, preoperative normovolemic hemodilution and intraoperative blood salvage. Nine subjects were affected by simple forms of craniosynostosis, whereas the remaining 4 presented with oxycephaly or craniofacial syndromes. Five of the 13 children were under 7 months and a further 3, under 10 months of age at the time of the surgical operation. Seven children weighed less than 10 kg. Allogeneic blood transfusion was avoided in 11 of the 13 children considered. Two failures - defined as the necessity to reinfuse the patient with an allogeneic blood transfusion - were recorded, 1 of them resulting from an unexpected hemorrhage during surgery. The results obtained indicate that this protocol designed to avoid allogeneic blood transfusion can be safely applied in the great majority of children with craniosynostosis, even when the surgical correction is carried out early in life.     

Continuous monitoring of blood volume in double filtration plasmapheresis

A continuous hematocrit (HCT) monitor, Crit-Line, was introduced to examine the change in patients' blood volume (BV) due to albumin loss during double filtration plasmapheresis (DFPP) treatments. Nine patients with autoimmune diseases or ABO incompatible renal transplantation received 15 DFPP treatments under Crit-Line monitoring. In these patients, plasma albumin concentration (C(P)) changed from 3.7 +/- 0.6 g/dl to 3.5 +/- 0.5 g/dl and HCT from 28.7% +/- 3.3% to 31.3% +/- 4.3% (change ratio [CR] of BV = -8.1%) during treatment with albumin concentrations (C(S)) of 9.5 +/- 1.0 g/dl and 500 ml volumes (V(S)) of supplementation fluid. Although the apparent CR value of C(P) was -5.3%, on average, the CR of albumin in the patients' plasma (M(P)) was -16.1%, which means a corrected CR value of C(P) by the HCT value to eliminate the influence of the patient's blood volume contraction during treatment. Albumin loss usually occurred in DFPP treatments. The decrease in BV was induced by an oncotic pressure drop due to albumin loss, and often resulted in a blood pressure drop. The amount of albumin loss during DFPP treatments strongly depends on sieving coefficients of the plasma separator (SC(PS)) and the plasma fractionator (SC(PF)), the filtration fraction of the plasma fractionator (FF(PF)), pretreatment C(P) value, and C(S) and V(S) values of the supplementation fluid. To determine the optimum C(S) and V(S) values for each patient, the authors introduced a variable blood volume model for albumin transport in DFPP. In this model, changes in C(P), HCT, and BV values could be estimated during treatment. For example, a patient with an HCT of 31.2%, body weight of 61.1 kg, and pretreatment C(P) of 4.4 g/dl received a DFPP treatment using a plasma separator, OP-05 (SC(PS) of 0.99), and a plasma fractionator, Evaflux 2A (SC(PF) of 0.40), under FF(PF) of 0.8 with a V(S) of 500 ml. A value for C(S) of about 10 g/dl is required for the patient to maintain a normal C(P) level during treatment by an estimation from the model. As a result of the treatment with a C(S) of 10 g/dl, the patient had no adverse reactions, such as a blood pressure decrease, during treatment under these conditions.     

The effects of perioperative blood salvage and autologous blood donation on transfusion requirements in scoliosis surgery

Fifty consecutive cases of surgical instrumentation and fusion for adolescent idiopathic scoliosis were prospectively studied to test the hypothesis that the use of predonated autologous blood combined with judicious perioperative blood salvage could decrease the amount of homologous blood needed. All cases had posterior instrumentation and fusion. Nineteen patients had their rib prominence resected with an average of 4.8 ribs per patient. Our protocol called for perioperative blood salvage with the cell saver and reinfusion of postoperative drained blood if more than 300 ml were drained in 4 hours. Two units of predonated autologous blood was made available. Hypotensive anesthesia and meticulous hemostasis kept the blood loss to a minimum. The average total blood loss was 1,055 ml. Blood loss per segment was 91 ml with an average of 11 segments fused per patient. Patients with rib resection had a blood loss of 1,105 ml, while those without had a blood loss of 955 ml. The cell saver blood returned per case was 391 ml with the hematocrit of the product averaging 46%. Twelve patients were reinfused an average of 300 ml of the postoperative drained blood. The predonated autologous blood was used as part of the intraoperative fluid management. In no patient was homologous blood needed. The average starting hematocrit was 35.6%, with the hematocrit at discharge (seventh day) being 32.4%. There were no complications or blood transfusion reactions. Our results suggest that judicious perioperative blood management may decrease the need for homologous blood transfusion in selected posterior idiopathic scoliosis surgery.     

Phase I study of orally administered UFT plus l-leucovorin

We describe the case of a 44-year-old woman with a delayed hemolytic transfusion reaction (DHTR). She had a history of two pregnancies and a blood transfusion, the details of which were unknown. At the time of her first vascular surgery on November 15, 1989, she received 1200 ml of crossmatch-compatible concentrated red blood cells (CRC). Before the first operation, screening for anti-RBC antibodies (Ab) was negative. At the time of the second admission on Feburary 15, 1996, anti-E Abs were detected by indirect antiglobulin test. She received 560 ml of E-antigen-negative, crossmatch-compatible, CRC for treatment of anemia on March 1 and 2, 1996. After this transfusion, total bilirubin (1.6 mg/dl) and lactate dehydrogenase (1355 IU/ml) were elevated on March 12, 1996. She had no evidence of clinical hemolysis. We suspected DHTR from these data, and therefore screened for anti-RBC Abs. Anti-E, Jka, Dia, Fyb, and S Abs were detected in blood samples obtained from the patient on March 12, 1996. Anti-E, Jka Dia, and S Abs were present more than 1 month and anti-Fyb Ab was disappeared at 18 days after transfusion.     

Contact dermatitis caused by cetrimide in antiseptics

Contact laser ablation of the prostate is distinct from other Nd:YAG laser prostatectomy techniques. Most Nd:YAG lasers function in a noncontact manner and rely primarily upon coagulation necrosis and delayed sloughing of the prostate tissue. The contact laser removes the obstructing prostate at the time of the procedure through immediate vaporization of the tissue. Since there is removal of tissue with the contact technique, fluid absorption and blood loss is a theoretical concern. Thirty-four patients with symptomatic benign prostatic hypertrophy who were candidates for traditional TURP were treated with contact laser ablation of the prostate (CLAP). Prostate sizes were 20-80 g, with a mean total gland size of 34 g. Serum hemoglobin and sodium levels were determined preoperatively and in the immediate postoperative period. The mean preoperative serum sodium level (mmol/L) was 138.4 (+/-3.6), and postoperatively 135.6 (+/-5.0). The mean change was -2.8 mmol/L (+/-4.8). The mean hemoglobin (g/dl) preoperatively was 14.4 (+/-1.5) and postoperatively 12.9 (+/-1.6). The mean change in hemoglobin was -1.5 g/dl (+/-0.8). No patient manifested any TUR syndrome or required transfusion. This study suggests that clinically significant changes in serum sodium and hemoglobin levels are not seen with contact laser vaporization of the prostate.     

"No allogeneic blood transfusion" protocol for the surgical correction of craniosynostoses. I. Rationale

Improved anesthesiological and surgical care has resulted in a progressively declining need for allogeneic blood transfusion. In infants with craniosynostosis, however, allogeneic blood transfusion is still performed as a routine procedure. In the present paper, the authors describe a protocol they have devised with the aim of limiting or even avoiding allogeneic blood transfusion even in very young patients, consequently avoiding the risks of infective or immunologic reactions associated with the procedure. The protocol is based on stimulation of the hematopoietic system with erythropoietin, selection of an appropriate age for operation when a favorable balance between fetal and adult-type hemoglobin is established (that is after 4-6 months), preoperative preparation of the autologous blood supply, and intraoperative blood salvage.     

Regulation of the Wilms'' tumour suppressor (WT1) gene by an antisense RNA: a link with genomic imprinting?

OBJECTIVE: To assess our experience with isolated iliac artery aneurysms and to assess the blood transfusion requirement in patients undergoing surgery for iliac artery aneurysms. MATERIAL AND METHODS: The case records of 12 patients who underwent 12 arterial reconstructive procedures for isolated iliac aneurysms from January 1989 to December 1995 were identified from our prospective vascular database and reviewed. Only patients with aneurysms limited to the common, external, or internal iliac arteries were included. RESULTS: Eleven patients had symptoms and rupture occurred in five patients. Aneurysmorrhaphy with graft interposition was the most common procedure. There was no perioperative mortality. The median transfusion requirement was 11 units per operation (range 1-30 units). The median intraoperative blood loss was 4700 ml (range < 500-13,000 ml). CONCLUSIONS: Isolated iliac aneurysm is a dangerous condition. A low perioperative mortality is possible only if large volumes of blood are available.     

Success in the radical resection of esophageal cancer with artificial blood infusion: case report

Using the oxygen-carrying, so-called "artificial blood", Fluosol-DA, developed by us, we successfully performed a radical resection for esophageal cancer and a one-stage reconstruction, without any blood transfusion. The operation was performed quite safely despite a large blood loss, a stable condition was performed quite safely despite a large blood loss, a stable condition being maintained during and after the operation. Fluosol-DA has no relation to blood type and is stable in a frozen state for one year or more and can, therefore, be used conveniently and safely for treating severe and intraoperative hemorrhages. Furthermore, this preparation may well have at wide application because it greatly reduces the risk of postoperative hepatitis.     

Quality assessment of intraoperative blood salvage and autotransfusion

Intraoperative blood salvage and autotransfusion are commonly used to minimize exposure to banked blood. Although this technique has been used widely for years, data vary regarding the quality of autotransfused blood. Salvaged blood may contain plasma, residual heparin, and free hemoglobin released from damaged cells. All of these factors may contribute to the adverse sequelae sometimes seen with autotransfusion. For these reasons, we have monitored autotransfused blood to assess its quality. Intraoperative blood salvage was used during most cardiac procedures and at the discretion of the surgeon in other specialties. Blood was collected through a double lumen catheter that was anticoagulated with heparin, filtered, centrifuged, and washed with saline. A sample of the blood was removed for analysis, which included hematocrit, heparin assay, fibrinogen, and free hemoglobin levels. Over a 6-year period, 1593 patients had intraoperative blood salvage with quality assessment. The majority of patients underwent cardiac operations (941 patients, 59%), whereas 243 had orthopedic (15%) and 208 had vascular (13%) procedures. Additionally, there were 127 pediatric patients (8%) and 74 miscellaneous procedures (5%). The highest average yield of salvaged blood was during vascular procedures (1073 +/- 76 mL), whereas orthopedic cases had the lowest yield (378 +/- 19 mL) and hematocrit (39%). There was minimal residual heparin activity, even in patients requiring systemic anticoagulation (0.3 to 0.5 units/mL). Patients undergoing pediatric procedures had the lowest concentration of free hemoglobin (476 mg/L), whereas all adult patients had higher free hemoglobin levels, especially vascular operations (990 mg/L). Intraoperative salvaged blood has minimal heparin activity, even in procedures requiring systemic anticoagulation. Fibrinogen, a marker of residual plasma, was undetectable in the majority of cases. These data indicate that intraoperative blood salvage generally results in a high-quality product (good hematocrit, low heparin, minimal plasma), although there are significant differences in free hemoglobin levels depending on the operative procedure.     

Leg blood flow and central circulation at various blood volumes: a peroperative study of nine patients with varicose veins

1. In a group of nine middle-aged patients undergoing varicose vein surgery, cardiac output, right atrial, pulmonary arterial and capillary pressures, and leg blood flow were measured after induction of general anaesthesia but before operation, and also during operation before and after blood substitution. 2. Under anaesthesia, the mean pre-operative blood flows in the superficial and common femoral arteries were 160 ml/min and 280 ml/min respectively. These flows are comparable with those obtained in other studies under similar conditions but lower than values obtained in conscious subjects. During the operation the leg blood flow decreased by 24%. As cardiac output remained unchanged, the fractional leg blood flow fell. After transfusion of 900 ml of blood the leg blood flow doubled. 3. It is concluded that anaesthesia, surgical trauma and variations in blood volume greatly influence the leg blood flow and that an adequate substitution of operative blood loss is of utmost importance to achieve an optimum peripheral circulation.     

Methods for reduction of homologous blood transfusions in operative medicine

For ethical and socio-economical reasons (cost-explosion in transfusion-medicine, patient's individual destiny), development and consistent application of allogeneic transfusion sparing techniques in surgery is a challenge to anesthesiologists, surgeons and blood-bankers. The combination of different techniques, i.e. autologous predonation, hemodilution, choice of anesthetic regimen, deliberate hypotension, application of antifibrinolytic agents and autotransfusion of intraoperatively saved blood allow for avoidance of allogeneic blood transfusion even in patients presenting important intraoperative hemorrhage. The present article summarizes (1) risks associated with transfusion of allogeneic blood, (2) actually applied pre- and intraoperative techniques to reduce transfusion of allogeneic blood and (3) new concepts (administration of erythropoietin, hyperoxic ventilation and administration of artificial oxygen carries) to further increase the efficacy of autologous predonation and preoperative normovolemic hemodilution.