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Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty
Voorn VM, van der Hout A, So-Osman C, Vliet Vlieland TP, Nelissen RG, van den Akker-van Marle ME, Dahan A, Marang-van de Mheen PJ, van Bodegom-Vos L
Vox Sanguinis. 2016;111((3):):219-225
Abstract
BACKGROUND AND OBJECTIVES To determine the value of erythropoietin in reducing allogeneic transfusions, it is important to assess the effects, safety and costs for individual indications. Previous studies neither compared the effects of erythropoietin between total hip and total knee arthroplasty, nor evaluated the safety or costs. We performed a meta-analysis to assess the effects of erythropoietin in total hip and knee arthroplasty separately. Safety and costs were evaluated as secondary outcomes. MATERIALS AND METHODS A systematic literature search was performed to identify randomized controlled trials evaluating the effect of erythropoietin in total hip and knee arthroplasty until April 2014. Study data were extracted using standardized forms and pooled using a random-effects model. Strength of the evidence was evaluated using Cochrane's Collaboration's tool for risk of bias assessment. RESULTS Seven studies were included (2439 patients). Erythropoietin significantly reduced exposure to allogeneic transfusion in both hip (RR 0.45; 95%CI 0.33-0.61) and knee (RR 0.38; 95%CI 0.27-0.53) arthroplasty, without differences between indications (P = 0.44). Mean number of transfused red blood cell units was significantly decreased in erythropoietin-treated patients (mean difference -0.57; 95%CI -0.86 to -0.29)(unable to split). No differences in thromboembolic or adverse events were found. Only one study evaluated costs, so that no pooled cost-effectiveness estimates could be given. CONCLUSION Erythropoietin is effective in both hip and knee arthroplasty and can be considered as safe. However, the decision to use erythropoietin on a routine base should be balanced against its costs, which may be relatively high.
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Patient blood management in elective orthopaedic hip-and knee replacement surgery: a report on clinical outcome
So-Osman C, Balradj J, Koopman-van Gemert AWMM, Onstenk R, van den Hout WB, Brand R, van Hilten JA, Brand A, Nelissen RGHH
Vox Sanguinis. 2016;111((S1)):282.. p-540.
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Patient blood management in elective total hip- and knee-replacement surgery (part 2): a randomized controlled trial on blood salvage as transfusion alternative using a restrictive transfusion policy in patients with a preoperative hemoglobin above 13 g/dl
So-Osman C, Nelissen RG, Koopman-van Gemert AW, Kluyver E, Poll RG, Onstenk R, Van Hilten JA, Jansen-Werkhoven TM, van denHout WB, Brand R, et al
Anesthesiology. 2014;120((4):):852-60.
Abstract
BACKGROUND Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion. METHODS Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. RESULTS In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by &OV0556;298 per patient (95% CI, 76 to 520). CONCLUSION In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.
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Patient blood management in elective total hip- and knee-replacement surgery (part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients
So-Osman C, Nelissen RG, Koopman-van Gemert AW, Kluyver E, Poll RG, Onstenk R, Van Hilten JA, Jansen-Werkhoven TM, van denHout WB, Brand R, et al
Anesthesiology. 2014;120((4):):839-51.
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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 &OV0556;785 per patient (95% CI, 262 to 1,309), that is, &OV0556;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 &OV0556;537 per patient (95% CI, 45 to 1,030). CONCLUSIONS 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.
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Cost effectiveness of patient blood management methods
So-Osman C
Vox Sanguinis. 2014;107((S1):):11.. 2c-s06-02.
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'Pre-operative iron' use as blood sparing technique in orthopaedic surgery (the POP-I study)
van Nordennen J, Koopman-van Gemert AWMM, So-Osman C, Zwaginga JJ, Nelissen RGHH
Vox Sanguinis. 2013;105((S1):):267.. Abstract No. P-604.
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A randomised controlled trial on erythropoietin and blood salvage as transfusion alternatives in orthopaedic surgery using a restrictive transfusion policy
So-Osman C, Nelissen RGHH, Koopman-van Gemert A, Kluyver E, Poll R, Onstenk R, Van Hilten JA, Jansen-Werkhoven TM, Brand R, Brand A
Transfusion Alternatives in Transfusion Medicine. 2011;12((1, Poster Abstracts):):25-26.
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Optimal blood management in elective orthopaedic surgery: the TRANSFUSIE OP MAAT (tailor made) study (the TOMAAT study) the first results
So-Osman C, Nelissen R, Koopman-van Gemert A, Jansen-Werkhoven T, Brand R, Brand A
Vox Sanguinis. 2010;99((Suppl S1):):427-428.. Abstract No. P-0923.
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Optimal blood management for elective orthopedic surgery: the Transfusie Op Maat (tailor made) study (TOMaat study)
So-Osman C, Nelissen R, Koopman-van Gemert A, Kluiver E, Poll R, Brand R, Brand A
Transfusion Alternatives in Transfusion Medicine. 2008;10((Suppl 1):):32. Abstract No. P37.
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10.
Efficacy, safety and user-friendliness of two devices for postoperative autologous shed red blood cell re-infusion in elective orthopaedic surgery patients: A randomized pilot study
So-Osman C, Nelissen RG, Eikenboom HC, Brand A
Transfusion Medicine (Oxford, England). 2006;16((5):):321-8.
Abstract
To determine the safety, efficacy and user-friendliness of two different postoperative autologous blood re-infusion systems, an open, randomized, controlled study was performed. Eligible consecutive primary and revision total hip and knee replacement patients were randomized for one of the two systems or for a control group in which shed blood was not re-infused. The nursing staff scored user-friendliness. Patients were monitored after re-infusion. In all three patient groups, a restrictive transfusion trigger was used. Sixty-nine of 70 randomized patients were evaluated. Ease of use, efficacy and safety of both re-infusion systems were comparable. There was no difference in allogeneic blood use between the groups. Thirty per cent of the patients re-infused with autologous blood developed a mainly mild, febrile transfusion reaction. No other adverse reactions were seen. Signs of coagulopathy after re-infusion were not found. In multivariate analysis, autologous re-infusion was an independent factor associated with a shorter hospital stay. Both postoperative autologous blood re-infusion systems were of equal efficacy and safety. The contribution of autologous wound blood re-infusion to reduce allogeneic transfusions must be investigated in a larger study.