Use Of Preoperative Autologous Donation Research Articles

Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes

Background context Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system. Purpose The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis. Study design/setting We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD). Patient sample This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied. Outcome measures The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies. Methods From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly. Results Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay. Conclusion The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.

The use of the orthopaedic perioperative autotransfusion (OrthoPAT) system in total joint replacement surgery.

Management of blood loss in orthopaedic surgery has evolved over the years. New approaches to making blood safer for patients has involved the use of preoperative autologous donation, the use of epoetin alfa administered preoperatively, intraoperative salvage, and perioperative salvage and infusion devices. A new alternative to salvage and infusion devices is the OrthoPAT. This article is meant to introduce the device to the orthopaedic nurse who works in the OR, PACU, and orthopaedic or medical-surgical unit, and who cares for orthopaedic patients who experience significant blood loss in total joint replacement surgery.

Cost effectiveness of epoetin-alpha to augment preoperative autologous blood donation in elective cardiac surgery.

The objective of this study was to assess the cost effectiveness of using epoetin-alpha (erythropoietin) to augment preoperative autologous donation (PAD) of blood prior to elective cardiac surgery. We designed a decision-analytic model incorporating the risk of receiving allogeneic blood, the costs of blood products, the likelihood of developing transfusion-related diseases, the costs of transfusion-related diseases and their impact on life expectancy, and the effect of epoetin-alpha on the probability of transfusion. The efficacy of epoetin-alpha was derived from data from a meta-analysis of published randomised trials comparing the use of epoetin-alpha to augment PAD with the use of PAD alone. Estimates for the other parameters were obtained by a systematic review of the literature. The use of epoetin-alpha reduced the proportion of patients receiving allogeneic transfusions by 60% (from 31.6 to 12.7%). However, this led to only a modest benefit of 0.000035 life years gained per patient and an incremental cost per life year gained of $Can44.6 million (1998 Canadian dollars). A detailed sensitivity analysis confirmed that the cost-effectiveness ratio was larger than that which is generally considered acceptable. Our study indicates that the use of epoetin-alpha to reduce perioperative allogeneic transfusions in cardiac surgery is not cost effective.

Determinants of physician ordering of preoperative autologous donations.

Preoperative autologous donation (PAD) is frequently utilized to reduce infectious disease transmission risks, but it is an expensive form of hemotherapy that is not always closely matched with the needs of the patients. We compared the use of PAD in an academic medical center with patient needs and then investigated the efficacy of a simple intervention to promote targeting of PAD toward patients most likely to benefit from having PADs available. Over a 3-month period, surgeons whose patients received allogeneic components were asked to complete a questionnaire designed to identify reasons for not ordering PAD. PAD units were used in 14 (11%) of 124 cases, accounting for 6% of perioperative red cell use. The responses (46, 42% of the surveys sent) stated that PAD had not been ordered because of time constraints (39%), medical problems (26%), anemia (15%), and lack of expectation of blood use (24%). Chart review documented the presence of cited conditions in 88% of cases. Logistic and cost concerns were not evident. However, only 8% of the 176 PAD units collected in that period were transfused. Following dissemination of PAD ordering guidelines, this proportion rose to 52% without a reduction in the proportion of elective surgical cases utilizing autologous transfusion. This improvement in ordering practice was maintained over at least in 5-month period. Thus we were able to improve the efficiency of PAD application (reducing over-ordering) through a simple feedback to surgeons that assisted them in targeting PAD toward patients most likely to need transfusion.

The safety of preoperative autologous blood donation in the nonhospital setting

The increasing use of preoperative autologous donation (PAD) of blood has led to more frequent donation in settings outside of hospitals, despite concerns that persons making PADs may face increased risks of postdonation reaction. Analysis was conducted of 5660 PADs made at 25 different blood centers, to determine the risks of PAD in nonhospital settings and to search for predictors of severe reactions. Sixteen percent (886) of the donations studied were by persons who did not meet all usual homologous donor criteria. The most common variances were for cardiovascular disease, including the use of cardiac drugs (416 donors, 41% of those not meeting criteria), history of angina (204, 23%), and history of myocardial infarction (192, 22%). Donation by persons not meeting routine criteria was followed by a higher reaction rate than that by donors without any variance (4.3 vs. 2.7%; p less than 0.0001). An increased likelihood of reaction was associated with donor age less than 17 years, female gender, weight less than 110 pounds, and a history of reaction. Four reactions were graded as severe (transient ischemic attack, 1; angina, 3), and all occurred in donors not meeting all criteria (0.4% of 886 donations). A review of these donors' histories failed to identify distinguishing features from which their severe reactions could have been predicted. This study documents the infrequency of severe reactions after PADs by persons referred to a blood center for donation, even those not meeting routine homologous donor criteria, and quantitates the risk to these donors of a severe reaction.