Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patient blood management (PBM). We will review to summarize the alternative measures and interventions used in bloodless surgery in the field of obstetrics and gynecology. In the obstetric field, PBM has been developed as an evolving evidence-based approach with a number of key goals: (i) to identify, evaluate, and manage anemia; (ii) reduce iatrogenic blood loss; (iii) optimize hemostasis; and (iv) establish decision thresholds for transfusion. Transfusion, mechanical method including balloon tamponade and uterine artery embolization, and intraoperative cell salvage were introduced for PBM. In the gynecologic field, PBM is not significantly different from that in the obstetric field. Preoperative managements include iron supplement, erythropoietin administration, autologous blood donation, and uterine artery embolization. Meticulous hemostasis, short operative time, hypotensive anesthetic techniques, hemodilution during operation, blood salvage and pharmacological agents were introduced to intraoperative management. Postoperative measures include meticulous postoperative monitoring of the patient, early detection of blood loss, reduction of blood sampling, appropriate use of hemopoiesis, normalization of cardio-pulmonary function and minimization of oxygen consumption. In conclusion, each obstetrician and gynecologist should be aware about the appropriate method for blood conservation and use in practice. A comprehensive approach to coordinating all members of the bloodless agent and surgical team is essential.
Anemia ; Balloon Occlusion ; Blood Donors ; Bloodless Medical and Surgical Procedures ; Erythropoietin ; Gynecology ; Hemodilution ; Hemorrhage ; Hemostasis ; Humans ; Iron ; Methods ; Obstetrics ; Operative Time ; Oxygen Consumption ; Uterine Artery Embolization

Despite improved perioperative management and surgical techniques, patients undergoing hepatobiliary and pancreatic (HBP) surgery often need to be transfused. Although disadvantages of transfusion and advantages of patient blood management (PBM) have been recognized, study results of the effects of PBM in HBP surgery are rare. The aim of this article was to review the current status of PBM in Korea in patients having HBP surgery. PBM in HBP surgery consists of increasing preoperative hemoglobin level, preoperative blood conservation, and preoperative autologous blood donation. The main intraoperative modalities used to conserve blood in recent studies were autologous techniques of acute normovolemic hemodilution and intraoperative cell salvage (Cell Saver®). In postoperative PBM, blood augmentation with erythropoietin and iron are also used depending on the postoperative hemoglobin level. Advances in surgical, anesthesiologic and pharmacologic strategies have contributed to a reduction of blood loss during HBP surgery in all patients.
Blood Donors ; Erythropoietin ; Hemodilution ; Humans ; Iron ; Korea

Patient blood management (PBM) is an evidence-based, patient-focused approach to optimize the management of patient and blood transfusion. While PBM is relatively well established in perioperative care, it is not as well established in the medical field. Since anemia in medical patients is heterogeneous and complex in its pathogenesis, the evidence for the threshold of hemoglobin for red blood cell (RBC) transfusion and the use of erythropoiesis-stimulating agents (ESAs) is not strong. While anemia seems to be an adverse risk factor for mortality, it is uncertain if rapid correction of anemia through RBC transfusion can reverse the negative impact of anemia on clinical outcomes. The introduction of ESA is a breakthrough in reducing RBC transfusion and managing anemic patients with renal disease and cancer. Despite promising results from early trials, the United States Food and Drug Administration issued a black box warning for ESAs in 2007 because of concerns about higher mortality, serious cardiovascular and thromboembolic events, and tumor progression. Therefore, the individualized approach to each patient with anemia is recommended in various medical conditions such as acute coronary syndrome, heart failure, chronic kidney disease, and malignancies.
Acute Coronary Syndrome ; Anemia ; Blood Transfusion ; Drug Labeling ; Erythrocytes ; Erythropoietin ; Heart Failure ; Humans ; Iron ; Mortality ; Perioperative Care ; Renal Insufficiency, Chronic ; Risk Factors ; United States Food and Drug Administration

Allogeneic blood transfusion is often restricted due to its adverse effects, a lack of blood supply, and religious or cultural constraints. As a result, patient blood management (PBM) has been gaining attention. PBM is an evidence-based, patient-centered bundle of technologies that manages perioperative anemia and reduces bleeding during surgery. PBM improves the postoperative prognoses. Perioperative anemia is the main concern in PBM; therefore, to diagnose and treat it is important. This review focuses on the perioperative use of oral or intravenous iron and erythropoietin (EPO), in relevant fields such as cardiac surgery, orthopedics, and neurosurgery. IV administration of iron has been controversial due to safety concerns, such as increased risk of infection. However, using IV iron appropriately is beneficial in most surgical settings. Although recombinant human EPO may increase thromboembolic risks, this can be mitigated through various methods including limiting the target Hb level, using it in combination with IV iron, or prophylaxis for deep venous thrombosis. EPO is recommended in patients undergoing cardiac or orthopedic surgery. As PBM becomes globally implemented, the blood management methods, including tranexamic acid, hemostatic agents, and cell salvage have become more variable as well. Among them, administration of iron and EPO would be the most common pharmacologic choices based on current practice. However, controversy still exists. Therefore, further studies on iron and EPO are needed to ensure better and safer patient care.
Anemia ; Blood Transfusion ; Bloodless Medical and Surgical Procedures ; Erythropoietin* ; Hemorrhage ; Humans ; Iron* ; Neurosurgery ; Orthopedics ; Patient Care ; Perioperative Care ; Prognosis ; Thoracic Surgery ; Tranexamic Acid ; Venous Thrombosis

Postoperative cognitive dysfunction (POCD) occurs immediately after surgery and is characterized by impairment of memory and changes in cognition. POCD can last for several months or years and have adverse effects including delayed hospital stays, diminished function in daily life, and increased complications and mortality. Despite improvements in surgical technique, anesthesia management, and intensive care, many patients suffer from POCD. POCD is one of the important clinical issues in surgical management and understanding its pathophysiology is necessary. In this review, therefore, we have focused on animal models of POCD and measurements of cognitive ability in preclinical studies, and we have suggested novel approaches for prevention/treatment of POCD. In preclinical studies, major abdominal surgery (laparotomy, hepatectomy, and splenectomy), minor abdominal surgery (laparotomy, probe exploration), and tibial fracture surgery, are used as POCD models. In addition, cognitive function is assessed by Morris water maze, passive avoidance task, elevated plus maze, and T maze test. Neuroinflammation, blood-brain barrier dysfunction, beta amyloid deposition, and tau phosphorylation are suggested as pathological mechanisms of POCD in preclinical studies. Based on several studies of these, we suggest erythropoietin, nuclear factor kappa B, interleukin17A, tumor necrosis factor alpha, and nicotinamide adenine dinucleotide phosphate oxidase 2 as candidates for prevention/treatment of POCD. In the preclinical stage, drug development/exploration and research is being carried out to solve cognitive dysfunction after surgery. Ultimately, based on the results of preclinical studies, we expect to overcome POCD.
Anesthesia ; Blood-Brain Barrier ; Cognition ; Critical Care ; Erythropoietin ; Hepatectomy ; Humans ; Length of Stay ; Memory ; Models, Animal ; Mortality ; NADP ; NF-kappa B ; Oxidoreductases ; Phosphorylation ; Plaque, Amyloid ; Tibial Fractures ; Tumor Necrosis Factor-alpha ; Water

Patients with hemolytic-uremic syndrome (HUS) can rapidly develop profound anemia as the disease progresses, as a consequence of red blood cell (RBC) hemolysis and inadequate erythropoietin synthesis. Therefore, RBC transfusion should be considered in HUS patients with severe anemia to avoid cardiac or pulmonary complications. Most patients who are Jehovah's Witnesses refuse blood transfusion, even in the face of life-threatening medical conditions due to their religious convictions. These patients require management alternatives to blood transfusions. Erythropoietin is a glycopeptide that enhances endogenous erythropoiesis in the bone marrow. With the availability of recombinant human erythropoietin (rHuEPO), several authors have reported its successful use in patients refusing blood transfusion. However, the optimal dose and duration of treatment with rHuEPO are not established. We report a case of a 2-year-old boy with diarrhea-associated HUS whose family members are Jehovah's Witnesses. He had severe anemia with acute kidney injury. His lowest hemoglobin level was 3.6 g/dL, but his parents refused treatment with packed RBC transfusion due to their religious beliefs. Therefore, we treated him with high-dose rHuEPO (300 IU/kg/day) as well as folic acid, vitamin B12, and intravenous iron. The hemoglobin level increased steadily to 7.4 g/dL after 10 days of treatment and his renal function improved without any complications. To our knowledge, this is the first case of successful rHuEPO treatment in a Jehovah's Witness child with severe anemia due to HUS.
Acute Kidney Injury ; Anemia* ; Blood Transfusion ; Bone Marrow ; Child* ; Child, Preschool ; Erythrocytes ; Erythropoiesis ; Erythropoietin* ; Folic Acid ; Hemolysis ; Hemolytic-Uremic Syndrome* ; Humans* ; Iron ; Jehovah's Witnesses ; Male ; Parents ; Religion ; Vitamin B 12

OBJECTIVETo study the relationship between the levels of erythropoietin (EPO) in serum and brain injury in preterm infants.

METHODSThree hundred and four preterm infants (gestational age: 28-34 weeks) born between October 2014 and September 2015 were enrolled in this study. Brain injury was diagnosed using cerebral ultrasound and MRI. The levels of EPO, S100 protein, neuron-specific enolase (NSE) and myelin basic protein (MBP) in serum were detected using ELISA. To compare the incidence of brain injury in different serum EPO levels in preterm infants, and the relationship between brain injury and serum EPO levels was analyzed.

RESULTSThe incidence rate of brain injury in preterm infants was 41.1% (125/304). The incidence rate of brain injury in the low EPO level group was significantly higher than that in the middle-high EPO level groups (P<0.01). The serum levels of S100 protein, NSE, and MBP in the brain injury groups were significantly higher than in the control group (P<0.01). The serum EPO levels were negatively correlated with serum S100 protein concentration and NSE levels (P<0.05). According to the multiple logistic regression analysis, low gestational age, low birth weight, asphyxia, prolonged mechanical ventilation, anemia and low serum EPO levels were the risk factor for brain injury in preterm infants.

CONCLUSIONSThere is a higher incidence rate of brain injury in preterm infants with lower serum EPO levels. The serum EPO levels may be correlated with brain injury in preterm infants.

Brain Injuries ; blood ; epidemiology ; Erythropoietin ; blood ; Female ; Humans ; Infant, Newborn ; Infant, Premature ; blood ; Male ; Myelin Basic Protein ; blood

PURPOSE: Lumbar fusion surgery was performed on transfusion-free patients and hemodynamic changes were analyzed. MATERIALS AND METHODS: A total of 36 transfusion-free patients who had undergone lumbar fusion surgery using recombinant human erythropoietin (rHuEPO) before surgery from April 2007 to March 2014 were included in the study. Hemoglobin and hematocrit levels were measured before surgery, immediately after surgery, 12 hours after surgery, on day 1, day 2, day 3, and day 7. Changes in levels were investigated and the factors affecting the changes in hemoglobin levels were analyzed. RESULTS: Changes in hemoglobin and hematocrit were -18.11% before surgery and -22.92% on day 7, respectively, and they tended to recover from day 2 after surgery. Depending on the patient's age, gender, body mass index, blood loss, and surgery method (presence of lumbar interbody fusion), the changes in hemoglobin level did not show statistically significant differences; however, significant differences were observed in the surgical time and extent of the operation. CONCLUSION: Transfusion alternatives during lumbar spinal fusion are deemed safe methods, leading to good, postoperative hemodynamic outcomes. However, the surgical time and extent of the operation must be determined before surgery.
Blood Substitutes ; Blood Transfusion* ; Body Mass Index ; Erythropoietin ; Hematocrit ; Hemodynamics* ; Humans ; Methods ; Operative Time ; Spinal Fusion ; Spine*

OBJECTIVETo investigate the expression level of erythropoietin (EPO) and ferritin before and after treatment of patients with iron deficiency anemia (IDA) so as to explore their clinical significance in diagnosis and discrimination.

METHODSThe EPO and ferritin levels in serum of 37 patients with IDA were determined by using chemiluminescence analysis (CLIA method) and electrical chemiluminescence analysis (ECLIA method), 30 healthy people were randomly selected as normal controls.

RESULTS(1) the sEPO level in IDA patients of group before treatment, group treated for 1 month and group treated for 2 months was higher than that in normal control group (P < 0.05). The level of sEPO of IDA patients in different groups after treatment was lower than that in IDA patients of groups before treatment, along with improvement of anemia status, the level of EPO was gradually reduced, and the level of sEPO in patients of group treated for 3 months was not statistical significant in comparison with that in normal control (P > 0.05). The level of ferritin in IDA patients before and after treatment was lower than that in normal control group (P < 0.05). The level of ferritin in IDA patient of groups after treatment was all higher than that in patients of groups before treatment, but comparision of serum ferritin level in patients of groups after treatment did not show statistical significance. (2) The level of logEPO in IDA patient before and after treatment was negatively related with level of Hb, but the level of ferritin in IDA patients was positively related with the level of Hb before treatment (r = 0.449, P = 0.005), the level of ferritin in patients of different group after treatment and in normal group did not related with level of HB. (3) The level of serum EPO in patients of severe anemia group was obviously higher than that in patients of moderate and mild anemia groups, and along with aggravation of anemia, the EPO level was gradually arised.

CONCLUSIONThe serum EPO is involved in the process of erythrocyte hematopoiesis, and can indicate the level of anemia, its sensitivity for anemia is higher than that of ferritin, and has important clinical value for evaluating status of diseases, observing therapeutic efficacy and judging prognosisi of IDA.

Anemia, Iron-Deficiency ; blood ; Case-Control Studies ; Erythropoietin ; blood ; Ferritins ; blood ; Humans

In a popular sense, Jehovah's Witnesses (JW) have their creeds, one of which is refusal of blood transfusion. Such refusal may impinge on their proper management, especially in critical situations. We present a case of successful bloodless multimodality therapy, which was performed for a JW. The patient was a 49-year-old woman and JW who had general weakness 7 days before admission. She was diagnosed with a pancreatic neuroendocrine tumor (PNET) with hepatic metastases. Transcatheter arterial chemoembolization and Sandostatin LAR injection were performed, and then she was given a transfusion-free Radical antegrade modular pancreatosplenectomy sequentially. We gave recombinant human erythropoietin and iron hydroxide sucrose complex daily for five days after surgery. She was discharged at postoperative day 12 without any surgical complications. Multimodality therapy is very important for optimal treatment of PNET. Along with intimate interdepartmental cooperation, careful patient selection and appropriate perioperative management could possibly enhance the surgical outcome.
Blood Transfusion ; Bloodless Medical and Surgical Procedures ; Disulfiram ; Erythropoietin ; Female ; Humans ; Iron ; Jehovah's Witnesses ; Middle Aged ; Neoplasm Metastasis ; Neuroectodermal Tumors, Primitive ; Neuroendocrine Tumors* ; Octreotide ; Pancreas* ; Pancreatectomy ; Patient Selection ; Sucrose