RESUMEN
Three cohorts of elective surgical patients were reviewed in order to develop a method in which the discharge haematocrit can serve as a clinical indicator for a subsequent study of the use of blood transfusion therapy. Three different levels of discharge haematocrit were evaluated: 36, 33, and 30% for 'generous', 'intermediate', and 'strict' criteria, respectively. Discharge haematocrits (%, mean +/- SD) for patients not transfused were 29.6 +/- 4.6, 33.7 +/- 5.0, and 33.6 +/- 3.4 for three different surgical groups (cardiac, orthopaedic, and urological surgical patients). When discharge haematocrits greater than 33% ('intermediate') were considered excessive due to previous transfusion, the prevalence of patients identified was 9, 6.5 and 13%, respectively. We found no relationship between the length of stay in hospital and the number of blood units transfused or patient discharge haematocrit levels. When the length of stay of patients identified by exceeding the clinical indicator was compared to that of patients not identified, orthopaedic and urological surgical patients showed no difference; however, cardiac surgical patients who exceeded the clinical indicator had shorter hospital stays compared to patients who were not so identified. We conclude the following: 1. The discharge haematocrit can be used as a clinical indicator for a subsequent review of use in order to evaluate the appropriateness of blood transfusion therapy. 2. The prevalence of patients identified who exceeded the clinical indicator, among three elective surgical patient groups, suggests that this indicator is applicable across elective surgical categories in order to target transfusion medicine education programmes and clinical outcome studies. 3. Additional factors important to the 'transfusion trigger', such as blood lost during hospitalization, may need to be included with the discharge haematocrit as clinical indicators in order to evaluate blood transfusion therapy in this setting.
Asunto(s)
Transfusión Sanguínea , Hematócrito , Auditoría Médica , Alta del Paciente , Procedimientos Quirúrgicos Operativos , Transfusión Sanguínea/normas , Transfusión Sanguínea/estadística & datos numéricos , Transfusión de Sangre Autóloga/normas , Transfusión de Sangre Autóloga/estadística & datos numéricos , Puente de Arteria Coronaria , Humanos , Tiempo de Internación , Masculino , Auditoría Médica/normas , Ortopedia , ProstatectomíaRESUMEN
We have analyzed the relationship between blood lost and blood transfusions given to 498 consecutive patients undergoing primary elective coronary artery bypass graft operations at 18 institutions. Seventy-nine percent of blood and 59 percent of patients were transfused only on the day of the operation. Patients who received none, 1 or 2 units of blood were not different when analyzed for blood transfusion risk factors except for the percentage of patients who were female. We identified 91 patients who received transfusion inappropriately, using a clinical indicator that analyzed blood losses for each patient. Forty-nine percent of all patients transfused could have avoided exposure to homologous blood if the equivalent of 4 units of the blood in erythrocyte volume had been provided for blood transfusion needs; if blood determined to have been transfused inappropriately had not been given, 95 percent of all patients would have received four or fewer erythrocyte units. We conclude that physician education and quality assurance programs need to be coupled with innovative blood conservation efforts that provide the equivalent of 4 units of homologous blood to minimize blood transfusions in this setting.
Asunto(s)
Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Transfusión Sanguínea/estadística & datos numéricos , Puente de Arteria Coronaria/estadística & datos numéricos , Volumen de Eritrocitos , Femenino , Hematócrito , Humanos , Masculino , Auditoría Médica , Persona de Mediana Edad , Análisis de Regresión , Factores de RiesgoRESUMEN
Previous studies have demonstrated that autologous blood donors have a suboptimal endogenous erythropoietin response to the mild anemia induced by blood donation. Recent studies in baboons subjected to aggressive phlebotomy have shown an acceleration of erythropoiesis that may be beneficial perioperatively. To address the issue of accelerated erythropoiesis in autologous blood donors, red cell production during an aggressive preoperative autologous blood donation program was analyzed. The volume of red cells increased 568 mL (27% over baseline) and 911 mL (47% over baseline) for 23 placebo and 21 erythropoietin-treated patients, respectively, by hospital admission (9 days after last drug administration and 26 days after beginning therapy). The mean rate of additional red cell production was 22 mL per day in the placebo group and 34 mL per day in the erythropoietin group (p less than 0.001), which represents a twofold and a 2.5-fold increase over basal erythropoiesis, respectively. The major difference in red cell production in the placebo and erythropoietin groups occurred early in the collection period. It can be concluded that an aggressive autologous blood phlebotomy program results in clinically important increased erythropoiesis at the time of surgery. In patients unsuited for aggressive autologous phlebotomy, a more modest autologous blood procurement program, coupled with the administration of recombinant erythropoietin, may be a preferable approach.
Asunto(s)
Transfusión de Sangre Autóloga , Eritropoyesis/efectos de los fármacos , Eritropoyetina/uso terapéutico , Eritropoyesis/fisiología , Humanos , Cuidados Preoperatorios , Proteínas Recombinantes/uso terapéuticoRESUMEN
Three hundred eleven patients with node-positive breast cancer were randomized to one of three adjuvant treatments: cyclophosphamide (Cytoxan), methotrexate, and 5-fluorouracil; all of the above with tamoxifen citrate; or all of the above with tamoxifen and bacillus Calmette-Guerin vaccination. Local therapy for all patients was a modified radical mastectomy. Estrogen receptors were measured on all primary tumors. Patients were stratified by the number of positive nodes (one to three nodes and more than three nodes) and estrogen-receptor value (less than 3 femtomole/mg and greater than or equal to 3 femtomole/mg). Follow-up is available, with a mean of 9.1 and maximum of 14.2 years. In this study the efficacy of short-term tamoxifen is apparent over that of chemoimmunotherapy alone and continues to be significant with prolonged follow-up. The addition of tamoxifen to chemoimmunotherapy significantly prolonged disease-free survival among patients with estrogen receptor-positive tumors who were postmenopausal, who had larger tumors (greater than 3 cm), or who had more extensive axillary node involvement (more than three nodes). Tamoxifen improved overall survival for patients with estrogen receptor-positive tumors larger than 3 cm. The addition of bacillus Calmette-Guerin Cytoxan, methotrexate, 5-fluorouracil, and tamoxifen did not significantly alter disease-free or overall survival.