Critical care : the official journal of the Critical Care Forum
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Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least 1 red blood cell (RBC) unit during their stay, and the average is close to 5 RBC units. RBC transfusion is not risk free. ⋯ In a randomized, placebo-controlled trial, therapy with rHuEPO resulted in a significant reduction in RBC transfusions. Despite receiving fewer RBC transfusions, patients in the rHuEPO group had a significantly greater increase in hematocrit. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the intensive care unit, and they decrease the transfusion threshold in the management of all critically ill patients.
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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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Trauma is the leading cause of death from age 1 to 34 years and is the fifth leading cause of death overall in the USA, with uncontrolled hemorrhage being the leading cause of potentially preventable death. Improving our ability to control hemorrhage may represent the next major hurdle in reducing trauma mortality. ⋯ The most important of these new drugs are injectable hemostatics, fibrin foams, and dressings. The available animal studies are encouraging and human studies are required.
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Persons who suffer traumatic injury are likely to be transfused with considerable amounts of blood during initial resuscitation efforts. Oxygen-carrying solutions are currently in clinical testing as substitutes for red blood cells. Although these agents may eliminate many concerns associated with blood administration (short shelf life, infectious and immunologic risks, the need to type and cross-match), early cell-free hemoglobin solutions demonstrated nephrotoxicity and were associated with pulmonary and systemic hypertension, among other adverse events. Newer polymerized hemoglobin solutions show acceptable safety profiles in the surgical setting and studies are being designed, some with funding from the US Department of Defense, to evaluate their efficacy in hemorrhaging trauma victims.
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Review Comparative Study
To filter blood or universal leukoreduction: what is the answer?
The safety of the blood supply has been a concern over the past 20-30 years because of the transmission of infectious diseases. Blood is still routinely tested for viruses, and leukoreduction is an effective strategy to reduce the transmission of cell-associated viruses. Clinically, the benefits of leukoreduction include decreases in transfusion reactions, HLA alloimmunization, infections, fever episodes, and antibiotic use. Although leukoreduction will add cost to a unit of blood, projections indicate that leukoreduced blood will become the standard of care.