Effect of haemodilution on transfusion requirements in liver resection

Effects of preoperative β-blocker on blood loss and blood transfusion during spinal surgeries with sodium nitroprusside-controlled hypotension

BACKGROUND

The present study sought to determine whether premedication with oral β-blocker before hypotensive anesthesia with sodium nitroprusside could improve the quality of surgical field, decrease the blood loss, and decrease the need for homologous blood transfusion and duration of surgery.

METHODS

Eighty patients scheduled for spinal fixation surgery were included in a prospective, randomized, double-blinded study. Patients were classified into two groups: Group I received oral atenolol 50 mg twice one day before surgery; and Group II received placebo tablets identical in appearance to atenolol tablets for the same period and interval. All patients in both the groups received intraoperative sodium nitroprusside (SNP) as a hypotensive agent. Hemodynamic variables, amount of sodium nitroprusside used, quality of surgical field, and the amount of homologous blood transfusion and blood loss were compared between groups.

RESULTS

Heart rate and amount of SNP used were significantly less (P<0.0001) in the atenolol group, but no significant difference was found in intraoperative mean arterial blood pressure (MABP) between the two groups. The time of surgeries was significantly shorter in Group I than in Group II (185±15.21 vs 225±12.61 min), P<0.0001. The quality of surgical field was better in Group I than in Group II in all times of measurements, P<0.0001. The amount of blood loss and the amount of packed red blood cells transfused were significantly less in Group I than in Group II, P<0.0001. No clinically significant complications were observed in either group.

CONCLUSION

Premedication with oral atenolol 50 mg twice/day for one day before hypotensive anesthesia with SNP during spinal surgeries seems to be clinically safe and effective to reduce heart rate, amount of SNP used, amount of blood loss, and amount of blood transfused with better quality of surgical field.

Effect of induced hypotensive anaesthesia vs isovolaemic haemodilution on blood loss and transfusion requirements in orthognathic surgery: a prospective, single-blinded, randomized, controlled clinical study

Induced hypotensive anaesthesia and isovolaemic haemodilution are well-established blood-sparing techniques in major surgery. This prospective study compared them for blood loss, transfusion requirements, and surgical field quality during standardized orthognathic operations. In a surgeon-blinded trial, 60 healthy patients requiring either Le Fort I osteotomy or bimaxillary surgery were randomly allocated to receive normotensive anaesthesia, induced hypotensive anaesthesia, or induced hypotensive anaesthesia combined with isovolaemic haemodilution. Blood loss and haemoglobin level were measured intraoperatively and calculated on postoperative day 3. The surgeons rated surgical field quality. Mean blood loss was 1021.63, 392.38 (p<0.05) and 1191.65ml in the normotensive, hypotensive and haemodilution groups, respectively. Mean haemoglobin level immediately after surgery was 9.3, 10.3, and 7.4g/dl (p<0.05), respectively. No hypotensive group patients received transfusions; four normotensive group patients required allogenic transfusions; seven haemodilution group patients needed autogenous retransfusions (p<0.05). Surgical field quality was significantly better in the hypotensive than in the normotensive (p<0.05) or haemodilution (p<0.05) groups. In orthognathic surgery, hypotensive anaesthesia significantly reduces blood loss and transfusion requirements and minimizes allogenic transfusions risks. Induced hypotensive anaesthesia combined with isovolaemic haemodilution has no additional blood-sparing effects but impairs surgical field quality.

Adjuncts to liver surgery: is acute normovolemic hemodilution useful for major hepatic resections?

For patients undergoing major hepatic resection, acute normovolemic hemodilution is a safe technique that effectively reduces allogeneic red blood cell transfusions. In the recent prospective randomized controlled trial completed at MSKCC, there was no difference in the extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, or length of hospital stay between patients who underwent ANH versus standardintraoperative management. Although ANH does reduce the rate o f allogeneic red blood cell transfusions in patients undergoing major hepatectomy, its benefit is particularly pronounced in patients who have significant operative blood loss (i.e., >800 mL). In these patients, the benefit of ANH extends also to the transfusion of FFP. Thus, ANH should be considered for routine use in patients undergoing major hepatectomy who have an expected considerable blood loss. However, given the relatively low transfusion rate overall, future efforts should be directed at preoperatively identifying patients most likely to benefit from ANH.

Intraoperative blood salvage during liver resection: a randomized controlled trial

OBJECTIVE

A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss.

BACKGROUND

Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established.

METHODS

Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed.

RESULTS

Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11-0.85, P = 0.025).

CONCLUSION

Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.

One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome

BACKGROUND

Many reports on blood loss and transfusion requirements during hepatectomy for metastatic liver cancer or hepatocellular carcinoma have been published; however, there are no reports on these issues in hepatectomy for biliary hilar malignancy. The aim of this study was to review our experience with blood loss and perioperative blood requirements in 100 consecutive hepatectomies for biliary hilar malignancy.

METHODS

One hundred consecutive hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for hilar malignancies were performed, including 81 perihilar cholangiocarcinomas and 19 advanced gallbladder carcinomas involving the hepatic hilus. Fifty-eight hilar resections were combined with other organ and/or vascular resection. Data on preoperative blood donation, intraoperative blood loss, and perioperative transfusion were collected and analyzed.

RESULTS

Preoperative autologous blood donation was possible in 73 patients (3.4 +/- 1.2 U). Intraoperative blood loss was 1850 +/- 1000 mL (range, 677-5900 mL), and it was < 2000 mL in 62 patients. Intraoperatively, only 7 of the 73 patients (10%) who donated blood received transfusion of unheated, homologous blood products (packed red blood cells or fresh frozen plasma), whereas 18 the 23 patients (67%) without donation received homologous transfusions. Only 16 patients received transfusion postoperatively, and overall, 35 patients received unheated homologous blood products. Total serum bilirubin concentrations after hepatectomy in patients receiving autologous blood transfusion only was similar to those in patients who did not receive transfusion. The incidence of postoperative complications was higher in the 35 patients who received perioperative homologous transfusion than in 65 patients who did not (94% vs 52%; P <.0001). The mortality rate (including all deaths) was 3% (myocardial infarction, intra-abdominal bleeding, and liver failure, 1 patient each).

CONCLUSIONS

Despite the technical difficulties arising from hepatectomy for biliary hilar malignancy, approximately two thirds of hepatectomies can be performed in an experienced center without perioperative homologous blood transfusion using preoperative blood donation.

The Effect of Erythropoietin on Allogeneic Blood Requirement in Patients Undergoing Elective Liver Resection: A Model Simulation

We investigated whether recombinant human erythropoietin (rHuEPO) administration would reduce red blood cell (RBC) transfusion requirements in patients undergoing elective liver resection. We retrospectively investigated 200 patients undergoing elective liver resection. Factors likely to predict perioperative RBC transfusion were studied using a logistic regression analysis. A mathematical model was used to simulate RBC transfusion requirements if (a). transfusion thresholds had been predefined at a hemoglobin concentration of 7-8 g/dL, (b). preoperative hemoglobin concentrations had been increased to 15 g/dL by rHuEPO administration in patients with preoperative hemoglobin concentration in the range 10-13 g/dL, and (c). both interventions had been used. A cost/benefit evaluation of rHuEPO administration formed part of this simulation. RBC transfusion was correlated with major and median liver resection, total liver vascular exclusion, and a combined nonhepatic abdominal surgery but was not correlated with a preoperative hemoglobin concentration in the range 10-13 g/dL. Adherence to a small transfusion threshold or rHuEPO administration alone would have resulted in a slight reduction in transfusion requirements and transfusion rates for the whole population. However, the two interventions in combination would have significantly reduced both variables. One-hundred-eighteen patients undergoing median and major liver resection received 92% of RBC transfused. Sixty-six of these 118 patients had preoperative hemoglobin concentrations in the range 10-13 g/dL and could have received rHuEPO before surgery. rHuEPO alone would have avoided the transfusion of 63 RBC packs of 203 in this subgroup and 12 transfused patients of 31 (P = 0.02). rHuEPO administration to these 66 patients would have cost 186000 Euro. The 63 RBC saved would have cost 10,710 Euro.

IMPLICATIONS

A mathematical model simulation suggests that the routine preoperative administration of erythropoietin to patients scheduled for major and median liver resection presenting with a preoperative hemoglobin concentration in the range 10-13 g/dL could reduce blood transfusion requirements. However, the cost/benefit ratio warrants consideration.

Autologous blood storage before hepatectomy for hepatocellular carcinoma with underlying liver disease

BACKGROUND

Preoperative autologous blood donation has been suggested for patients with liver disease who are to undergo liver resection. The aim of this retrospective study was to clarify the risk factors for increased blood loss and the need for blood transfusion during hepatectomy for hepatocellular carcinoma (HCC).

METHODS

From January 1996 to December 2000, 206 consecutive patients, 98.5 per cent of whom had underlying liver disease, underwent elective hepatectomy for HCC.

RESULTS

Major hepatectomy was performed in 34 patients (16.5 per cent) and minor hepatectomy in 172 patients (83.5 per cent). The mean blood loss was 410 (median 260) ml. Eleven (5.3 per cent) of the 206 patients received blood transfusion during or after the operation. Operation time (P = 0.004) and central venous pressure (CVP) (P = 0.041) were independently correlated with blood loss of more than 1000 ml. Only preoperative haemoglobin level (P = 0.001) was independently correlated with the need for blood transfusion.

CONCLUSION

In patients with underlying liver disease, maintaining CVP at a level below 5 cm H2O during parenchymal transection to reduce blood loss is more important than reserving autologous blood before the operation.

Acute normovolemic hemodilution for radical prostatectomy: can it replace preoperative autologous blood transfusion?

BACKGROUND

Although preoperative autologous blood donation (PAD) is accepted as a standard of care for radical prostatectomy, it is costly, time-consuming and has risks associated with blood storage. Acute normovolemic hemodilution (ANH) is reported to be less expensive and to preserve blood components more effectively than PAD. In the present study, the efficacy and safety of these two autologous blood-collection techniques were compared.

METHODS

The study included 16 consecutive patients scheduled for radical prostatectomy. The first eight patients underwent conventional preoperative autologous blood donation of 400 mL 1 week before the operation (PAD group) and the second eight patients underwent acute normovolemic hemodilution followed by immediate operation (ANH group). All blood collected was transfused in the perioperative period. Preoperative and postoperative hematocrit levels in these two groups were compared.

RESULTS

There were no differences in preoperative hematocrit, time of operation or operative blood loss between the two groups. In the ANH group, 1080 +/- 160 mL of blood were collected. The postoperative hematocrit level did not differ significantly between the groups. No patient in either group received allogeneic blood transfusion or experienced an adverse event directly related to blood transfusion.

CONCLUSION

The two blood-conservation strategies resulted in similar postoperative hematologic outcomes. Given its advantages, which include lower cost, lower risk and higher convenience, ANH is one of the procedures that may replace conventional PAD for use in radical prostatectomy.

Reduction of transfusion requirements during major hepatic resection for metastatic disease

BACKGROUND

Our purpose was to determine whether the combination of total liver vascular inflow occlusion (Pringle maneuver) and rapid hepatic transection with a clamp-crush technique results in significant reduction of blood loss and transfusion requirements during major hepatic resections.

METHODS

A series of 49 adult patients underwent major hepatic resections for metastatic disease between April 1, 1992, and March 31, 1998. Group 1 patients (n = 15) had standard hilar dissection and finger-fracture hepatic transection without total liver inflow occlusion. Group 2 patients (n = 34) had total liver inflow occlusion and clamp-crush parenchymal transection.

RESULTS

Median blood loss was 1600 mL for group 1 and 500 mL for group 2 (P = .001). Eleven (73%) patients in group 1 required intraoperative blood transfusion (median 2 units) compared with 7 (21%) in group 2 with a median of 0 units (P = .001 and P < .001, respectively). Of the 7 patients in group 2 who required transfusion, 3 had a preoperative hemoglobin below 10 g/dL, 1 required splenectomy for operative injury, and 1 underwent a concomitant complicated small bowel resection.

CONCLUSIONS

Major hepatic resections can be performed without transfusion of blood products when preoperative hemoglobin is above 10 g/dL and concomitant major surgical procedures are not required.

Reduced transfusion requirements during major hepatic resection with use of intraoperative isovolemic hemodilution

BACKGROUND

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of tumor recurrence and decreased survival in some series. Isovolemic hemodilution (IH) has been utilized in cardiac, orthopedic, and major general surgery procedures to reduce the use of banked blood products. We therefore sought to determine the safety and efficacy of IH during major hepatic resection in an adult population.

METHODS

Thirteen consecutive patients undergoing major hepatic resection with IH were compared with 13 age- and disease-matched controls. The diseases included metastatic colorectal adenocarcinoma (8 versus 9), hepatoma (2 in each group) and other (3 versus 2); and the procedures included total (right or left) hepatic lobectomy (8 versus 11), partial lobectomy (3 versus 1) and trisegmentectomy (2 versus 1).

RESULTS

There was no significant difference in operating time, estimated blood loss, fresh frozen plasma, platelets, amount of crystalloid or colloid infused between the two groups. There was no perioperative morbidity related to IH. The use of IH resulted in a 60% reduction in mean packed red blood cells transfusion during major hepatic resection. Only 38% of patients undergoing IH required packed red cells transfusion, whereas 77% of historical control patients required allogenic transfusion.

CONCLUSION

The use of IH reduces the need for homologous transfusion during major hepatic resection. IH is a safe technique during hepatic resection and is not associated with perioperative morbidity.

Use of preoperative autologous blood donation in liver resections for colorectal metastases

BACKGROUND

Transfusion of allogeneic blood is associated with risks of human immunodeficiency virus and hepatitis transmission, transfusion reactions, and other potential immunologic and infectious complications. To determine if predonation of autologous blood impacts upon transfusion practice and clinical outcome following liver resection, clinical records of 379 consecutive patients undergoing hepatic resection for metastases of colorectal cancer were identified from the prospective hepatobiliary database and reviewed.

METHODS

Of the 379 hepatic resections performed for colorectal metastases between January 1991 and January 1996, 240 (63%) were hepatic lobectomy or trisegmentectomy. Thirty-two percent of patients (123 of 379) agreed to preoperative blood donation (POBD), and their clinical characteristics including age, preoperative hemoglobin, and operative mortality were comparable with those of patients without POBD. Liver resections were carried out using standard vascular inflow and outflow control. Parenchymal transections were performed bluntly with maintenance of low central venous pressure (0 to 5 cm H2O). No vascular isolation or normovolemic hemodilution was used intraoperatively. All erythrocyte transfusions during the entire hospital stay were considered and compared between the two groups.

RESULTS

Forty-five percent of patients (172 of 379) received blood transfusions during or after liver resections, of which 61% (105 of 172) required only 1 or 2 units. Only 17% of the POBD group required allogeneic blood. This was significantly less than the group without POBD (43%, P <0.01). There was no significant difference in the operative mortality (2.3% versus 4.9%, P = 0.2) and the median survival (50 versus 40 months, P = 0.3).

CONCLUSIONS

Major hepatic resections using current surgical techniques can be performed safely with low blood loss and transfusion is required for only a minority of patients. POBD further reduces transfusion requirement.

Acute isovolemic hemodilution during major hepatic resection--an initial report: does it safely reduce the blood transfusion requirement?

Surgical resection remains the mainstay of treatment for patients with hepatic tumors, despite the associated morbidity including the need for blood transfusion. Acute isovolemic hemodilution (AIH) has been shown to decrease the transfusion requirement for cardiac, urologic, and orthopedic procedures. However, the reported experience with AIH during hepatic resections is limited. Seven patients underwent major hepatic resection from July 1992 to June 1994 with standard AIH. Their clinical parameters were compared with those of nine matched control patients during the same time period. AIH and control patients had similar preoperative laboratory values (hematocrit, bilirubin, and coagulation studies), extent of liver resection, and pathologic diagnoses. Mean tumor diameters were larger in the AIH group (9.3 cm vs. 5.8 cm). Most important, patients managed with AIH required homologous blood transfusions significantly less often than the control group (14% vs. 67%; P=0.05). Furthermore, if they did receive transfusions, AIH patients needed fewer units of red cells (0.1+/-0.1 units vs. 1.7+/-0.6 units). There was no morbidity associated with AIH. AIH can be safely performed in patients undergoing major hepatic resection for malignancy. AIH appears to reduce the number of patients requiring homologous blood transfusion as well as the number of units transfused per patient. This technique warrants further study in a larger prospective, randomized trial.

Aprotinin reduces blood loss in patients undergoing elective liver resection

Ninety-seven patients undergoing elective liver resection through a subcostal incision were assigned to large-dose aprotinin treatment or placebo in a double-blind, prospective, randomized fashion. Randomization was stratified by diagnosis: (a) cancer in cirrhosis, (b) cancer in healthy liver, and (c) benign tumor in healthy liver. Intraoperative blood loss, percentage of transfused patients, and total transfusion requirement per group were significantly lower in the aprotinin group than in the placebo group (1217 +/- 966 mL vs 1653 +/- 1221 mL, P = 0.048; 17% vs 39%, P = 0.02; 30 vs 77 red blood cell packs, P = 0.015, respectively). Assessment of hematological markers (a) prior to surgery, (b) at the end of surgery, and (c) 24 h after surgery showed an identical intraoperative increase in thrombin-antithrombin III complexes in patients of both groups (P = 0.86), which indicates a similar activation of coagulation. Intraoperative hyperfibrinolysis was significantly less pronounced in the aprotinin group than in the placebo group (P = 0.0002 and P = 0.004 for D-dimers and fibrinogen, respectively). No adverse drug effects were detected (circulatory disturbances, deep venous thrombosis, increase in serum creatinine). These results suggest that aprotinin significantly reduces blood loss and transfusion requirement in patients undergoing elective liver resection through a subcostal incision.

Preoperative acute hypervolemic hemodilution with hydroxyethylstarch: an alternative to acute normovolemic hemodilution?

Acute normovolemic hemodilution (ANH) may help to reduce demand for homologous blood but requires extra time and apparatus. A more simple procedure is acute hypervolemic hemodilution (HHD), where hydroxyethylstarch is administered preoperatively without removal of blood. In a prospectively randomized study we compared ANH (preoperatively 15 mL/kg autologous blood removal and replacement with 15 mL/kg of hydroxyethylstarch with HHD (15 mL/kg of hydroxyethylstarch administered preoperatively) in 49 patients undergoing hip arthroplasty. To avoid excessive intravascular volume, we used the vasodilating effect of isoflurane. No significant differences were found between groups (ANH, n = 23; HHD, n = 26) for intraoperative blood loss (ANH versus HHD, median [minimum-maximum]); 545 [295-785] mL versus 520 [315-825] mL) and postoperative blood loss (730 [525-945] mL versus 780 [495-895] mL), postoperative hemoglobin, hemotocrit, platelet count or coagulation variables, and transfusion requirements (ANH 43% versus HHD 35% of patients received homologous blood) (P > 0.05). Heart rate did not change significantly in either group. In the ANH group mean arterial blood pressure (MAP) decreased after hemodilution (P < 0.05) while in the HHD group MAP did not change over time. Mean time required to perform ANH was 58 (46-62) min versus HHD 16 (12-19) min (P < 0.05). Costs for ANH were $63.60 USD and for HHD $32.75 USD (labor costs not included). In orthopedic patients undergoing hip replacement with a predicted blood loss of about 1000 mL, HHD seems to be a simple as well as time- and cost-saving alternative for ANH.

Hepatic resections in normothermic ischemia

BACKGROUND

Reduction of operative blood transfusions is a primary goal in resective surgery of the liver. Temporary vascular inflow occlusion is an effective method to decrease hemorrhage during hepatic resection. This study was performed to assess the impact of normothermic ischemia on intraoperative bleeding and outcome after hepatic resection.

METHODS

Sixty-one hepatic resections were performed by using pedicle clamping alone or associated with total vascular exclusion of the liver. The mean duration of normothermic ischemia was 40 +/- 18 minutes (range, 7 to 98 minutes). Major resections were performed in 32 cases (52.5%).

RESULTS

Operative mortality was nil. Major complications occurred in 11.5% of cases. Twenty-five patients (41%) received intraoperative blood transfusions; mean +/- SD of transfused blood units was 2.4 +/- 1.3. Twelve major resections (37.5%) did not require any transfusion. Postoperative changes in liver function test results were moderate and transient.

CONCLUSIONS

The results of this study confirm the benefit of vascular occlusion techniques in reducing intraoperative bleeding and postoperative complications. The routine use of these techniques during hepatic resections, if applied properly and with the necessary precautions, is not associated with severe adverse effects on liver function.

Alternatives to allogeneic blood use in surgery: acute normovolemic hemodilution and preoperative autologous donation

Acute normovolemic hemodilution (ANH) is a common blood conservation strategy in elective surgical procedures. Moderate ANH is safe in patients > 60 years of age; ANH is not recommended for patients who have coronary artery disease, significant anemia, renal disease, severe hepatic disease, pulmonary emphysema, or obstructive lung disease. Preservation of oxygen delivery during ANH depends on the maintenance of normovolemia to avoid decompensation and falling cardiac output. Preoperative autologous donation (PAD) as a blood conservation strategy has the advantage of protecting the patient from risks associated with allogenic transfusion, but it is expensive and time consuming. No protocols have established a preference for either ANH or PAD; an early study suggested that ANH is less expensive and more effectively preserves blood components, but other researchers warn that the methodology for ANH remains unresolved.

Liver resection without blood transfusion

A retrospective study was carried out of 522 elective liver resections to determine the impact of blood transfusion on the immediate postoperative outcome and on long-term survival. The number of liver resections without transfusion has increased in recent years, as a result of improvement in surgical technique with less blood loss during operation and more careful choice of the timing of transfusion. In resections carried out in the past 5 years, the indication for intraoperative transfusion was restricted and the decision was made jointly by the surgeon and anaesthetist, and in any case only if the haematocrit was below 25 per cent. Of resections carried out in the past 2 years, 59 per cent did not require intraoperative transfusion. Postoperative deaths and complications were related to blood transfusion, particularly in patients with cirrhosis, in whom stepwise logistic regression analysis showed that transfusion was the only factor that correlated significantly with complications. Transfusion also affected the long-term survival of patients operated on for hepatocellular carcinoma and colorectal carcinoma metastases in univariate analysis and was the only factor shown by multivariate analysis to correlate with survival for hepatocellular carcinoma in patients with cirrhosis.

Surgical options in the treatment of hepatic metastasis from colorectal cancer

Current data indicate that liver resection is the only available treatment that regularly produces long-term survival with possible cure in patients with metastatic colorectal carcinoma to the liver. Although a number of clinical or pathologic factors predicts a poor outcome, the only absolute contraindications to liver resection are general health incompatible with recovery from major hepatic resection or clear evidence of wide dissemination of disease. Important areas for future study include the potential role of adjuvant regional chemotherapy after resection and cryoablation of "close" margins. For patients with unresectable disease, operative therapy also plays an important role. Multiple operative modalities hold promise in palliative treatment in the setting of clinically incurable disease. It is imperative that a large randomized trial of regional chemotherapy be performed allowing no crossover and with mortality as an endpoint. Additionally, the role of cryoablation begs systematic investigation to ensure proper use of this modality.

Haemodilution study in major orthopaedic surgery experience as a technique of blood conservation

Haemodilution and auto-transfusion were carried out in 103 consecutive patients having major orthopaedic surgery. The records of 99 patients were available for retrospective assessment of this technique. Fifty-six per cent of the patients did not require any homologous blood transfusion. Homologous blood transfusion was given to 44% of the patients, who used up 99 units of blood in their entire hospital stay. There was no morbidity such as transfusion reaction, infection, decrease in platelets or re-operation for bleeding associated with the procedure, although there was one death secondary to myocardial infarction. This technique offered an alternative method to reduce the use of homologous blood transfusion in major orthopaedic operations.

Transfusion and surgery

In this survey of transfusion in surgery, we have attempted to provide the surgeon with an understanding of the problems associated with homologous transfusion and a practical knowledge of treatment strategies and alternatives designed to reduce homologous blood exposure. Such a review cannot be encyclopedic. Our hope is that it will serve the reader as a stimulus to examine his or her transfusion practices and as a guide for future self-learning.