Two-shoot Erythropoietin Injection coupled with Acute Normovolumic Hemodilution as Allogenic Blood transfusion Sparing Strategy

Objectives: To evaluate the beneficial effects of perioperative preparation of patients, undergoing hiparthroplasty, by two-shoot erythropoietin (EPO) injection with iron supplements on frequency and amount of perioperative allogenic blood transfusion. Patients Methods: The study comprised 40 ASA II patients assigned to undergo elective hip arthroplasty randomly allocated in 2 groups (n=20): Control group assigned to receive allogenic blood transfusion if they required and Epoietin-alfa group (EPO group) assigned to receive perioperative erthyropoietin (600 lU/kg up to a maximum dose of 40 000 lU/injection at 28 and 14 days prior to surgery) with co-administration of pure iron oral medication (3 tablets daily for42 days), and underwent Acute Normovolumic Hemodilution (ANHD) procedure started after induction of anesthesia and completed before start of surgery. Results: Preoperative hemoglobin concentration (Hbconc.) showed significant increase compared to their baseline measures and to control group with a 15.7% increase in Hb conc. compared to baseline measures. Increased Hb conc. was associated with a significant decrease in serum iron and ferritin concentrations in EPO group compared to control group. Hb conc., showed a non-significant increase after ANHD procedure and at start of surgery but showed a significant increase at post-transfusion and at time of discharge in EPO group compared to control group. Coagulation profile showed a non-significant difference between both groups until the start of transfusion therapy but was significantly different in favor of EPO group after transfusion. All patients required blood transfusion, but only 3 patients in EPO group required supplemental allogenic blood transfusion with a rate of allogenic blood transfusion was 15%, whereas all patients encompassed in control group received allogenic blood transfusion with a significant reduction of the frequency of allogenic blood transfusion infavor of EPO group, but with a non-significant difference between the numbers of blood units used in both groups. No mortality, neurological deficits (e.g., strock), signs of myocardial ischemia or pulmonary embolism was reported. All patients underwent lower limb duplex ultrasonography on the 5th postoperative day, 6 patients (15%) required re-evaluation, 4 patients were asymptomatic; 3 in EPO group and one in control group, while 2 patients were symptomatic; one in each group. Conclusion: Preoperative S.C. administration of epoietin-alfa at 4 and 2 weeks prior to surgery (in a total dose of 40 000 lU/injection) coupled with oral iron therapy proved to enhance erythropoiesis and significantly reduced the risk for allogenic blood transfusion to 15%. Moreover, the combination of preoperative epoetin-alfa therapy and ANHD procedure improved post-transfusion hemoglobin concentration and coagulation profile, reduced the frequency of postoperative DVT, and proved to be a proper allogenic blood transfusion -sparing strategy.