From the Department Center of Clinical Transfusion Research, Sanquin Blood Supply, Leiden, The Netherlands (C.S.-O., J.A.V.H., and A.B.); Department of Orthopedic Surgery, Leiden University Medical Center, RC Leiden, The Netherlands (R.G.H.H.N.); Department of Anaesthesiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands (A.W.M.M.K.-v.G.); Department of Anaesthesiology, Slotervaart Hospital, Amsterdam, The Netherlands (E.K.); Department of Orthopedic Surgery, Slotervaart Hospital, Amsterdam, The Netherlands, and VU University Medical Center, Amsterdam, The Netherlands (R.G.P.); Department of Orthopedic Surgery, Groene Hart Hospital, Gouda, The Netherlands (R.O.); Department of Medical Statistics and BioInformatics, Leiden University Medical Center, Leiden, The Netherlands (T.M.J.-W. and R.B.); Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands (W.B.v.d.H.); and Department of Immunohaematology and Blood Transfusion Service, Leiden University Medical Center, Leiden, The Netherlands (A.B.).
Anesthesiology. 2014 Apr;120(4):839-51. doi: 10.1097/ALN.0000000000000134.
Patient blood management combines the use of several transfusion alternatives. Integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices on allogeneic erythrocyte use was evaluated using a restrictive transfusion threshold.
In a factorial design, adult elective hip- and knee-surgery patients with hemoglobin levels 10 to 13 g/dl (n = 683) were randomized for erythropoietin or not, and subsequently for autologous reinfusion by cell saver or postoperative drain reinfusion devices or for no blood salvage device. Primary outcomes were mean allogeneic intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness.
With erythropoietin (n = 339), mean erythrocyte use was 0.50 units (U)/patient and transfusion rate 16% while without (n = 344), these were 0.71 U/patient and 26%, respectively. Consequently, erythropoietin resulted in a nonsignificant 29% mean erythrocyte reduction (ratio, 0.71; 95% CI, 0.42 to 1.13) and 50% reduction of transfused patients (odds ratio, 0.5; 95% CI, 0.35 to 0.75). Erythropoietin increased costs by €785 per patient (95% CI, 262 to 1,309), that is, €7,300 per avoided transfusion (95% CI, 1,900 to 24,000). With autologous reinfusion, mean erythrocyte use was 0.65 U/patient and transfusion rate was 19% with erythropoietin (n = 214) and 0.76 U/patient and 29% without (n = 206). Compared with controls, autologous blood reinfusion did not result in erythrocyte reduction and increased costs by €537 per patient (95% CI, 45 to 1,030).
In hip- and knee-replacement patients (hemoglobin level, 10 to 13 g/dl), even with a restrictive transfusion trigger, erythropoietin significantly avoids transfusion, however, at unacceptably high costs. Autologous blood salvage devices were not effective.
患者血液管理结合了几种输血替代方法的使用。在异体红细胞使用时采用限制性输血阈值，评估促红细胞生成素、细胞保存器和/或术后引流再输注装置的综合使用。
在析因设计中，血红蛋白水平为 10 至 13 g/dl 的择期髋关节和膝关节手术成年患者（n = 683）随机接受促红细胞生成素或不接受，随后接受细胞保存器或术后引流再输注装置的自体再输注，或不使用任何血液回收装置。主要结局为平均异体术中及术后红细胞使用量和输血患者比例（输血率）。次要结局为成本效益。
使用促红细胞生成素（n = 339）的患者平均红细胞使用量为 0.50 单位（U）/患者，输血率为 16%，而不使用促红细胞生成素（n = 344）的患者分别为 0.71 U/患者和 26%，因此，促红细胞生成素导致平均红细胞减少 29%（比值，0.71；95%CI，0.42 至 1.13）和输血患者减少 50%（优势比，0.5；95%CI，0.35 至 0.75），但差异无统计学意义。促红细胞生成素使每位患者的成本增加了 785 欧元（95%CI，262 至 1309 欧元），即避免每次输血的成本为 7300 欧元（95%CI，1900 至 24000 欧元）。使用自体再输注时，使用促红细胞生成素的患者平均红细胞使用量为 0.65 U/患者，输血率为 19%（n = 214），不使用促红细胞生成素的患者分别为 0.76 U/患者和 29%（n = 206）。与对照组相比，自体血液再输注并未减少红细胞用量，反而使每位患者的成本增加了 537 欧元（95%CI，45 至 1030 欧元）。
在髋关节和膝关节置换患者（血红蛋白水平为 10 至 13 g/dl）中，即使采用限制性输血触发，促红细胞生成素也能显著减少输血，但成本高得令人无法接受。自体血液回收装置无效。
