Critical care : the official journal of the Critical Care Forum
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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.
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The decision to transfuse a hospitalized patient must balance the known risks of transfusion with the need to provide adequate tissue oxygenation and the appropriate utilization of blood as a scarce resource. The minimum tolerated hemoglobin level is not well established, and considerable variation exists in intensivists' transfusion practices. ⋯ Evidence from randomized trials also indicates that withholding transfusions may result in improved outcomes. Arbitrary numeric hemoglobin triggers, however, cannot supercede intervention based on individual physiologic need and clinical circumstances.
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The quality and economy of critical care could both be improved if blood losses due to phlebotomy and sampling from indwelling catheters for unnecessary diagnostic testing were curtailed. Practice guidelines can help to break bad diagnostic 'habits', such as fever work-ups that require substantial blood to be drawn yet typically yield little useful information. ⋯ Several devices allow blood that would otherwise be wasted during sampling to be returned to the patient aseptically. Point-of-care testing uses microliter quantities of blood, has acceptable precision, and can provide valuable diagnostic information while being minimally invasive.
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Blood transfusions remain common practice in the critical care and surgical settings. Transfusions carry significant risks, including risks for transmission of infectious agents and immune suppression. Transmission of bacterial infections, although rare, is the most common adverse event with transfusion. ⋯ Numerous studies have been performed to examine the role of leukoreduction in decreasing these transfusion-related complications but results remain contradictory. We review the infectious risks associated with blood transfusion and the most recent data on its immunologic effects, specifically on cancer recurrence, mortality, and postoperative infections in surgical patients. We also review the use of leukoreduction in blood transfusion and its role in preventing transfusion-transmitted infections and immunomodulatory complications.