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RECOMMENDATION Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period.

Giancarlo Maria Liumbruno1, Francesco Bennardello2, Angela Lattanzio3, Pierluigi Piccoli4, Gina Rossetti5 or t!e "talian #ociet$ o %rans usion Medicine and "mmuno!aematolog$ &#"M%"' (or)ing Part$

Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, "San Giovanni Calibita" atebenefratelli !os"ital, #ome$ %Service of Immunohaematology and Transfusion Medicine, "Civile&Maria Patern' (re))o" !os"ital, #agusa$ *Service of Immunohaematology and Transfusion Medicine, !os"ital of Carbonara, +ari$ , Service of Immunohaematology and Transfusion Medicine, !os"ital of -erona, -erona$ .Service of Immunohaematology and Transfusion Medicine, !os"ital of Trento, Trento$ Italy Re,eated sam,ling o blood to carr$ out laborator$

Aetiology and prevention of anaemia Prevalence of anaemia

basis o arbitrar$ c!oices, rat!er t!an on real clinical needs1/

*arious studies !a+e documented t!e !ig! ,re+alence Aetiology of anaemia o anaemia and t!e re-uent use o trans usions o Post.o,erati+e anaemia allogeneic blood and blood com,onents in t!e ,ost. ma$ be caused b$ +arious o,erati+e ,eriod1. 5/ "n a ,ros,ecti+e, obser+ational, actors? acute or c!ronic multicentre stud$ carried out in 0uro,e in 1111 on 3,534 blood loss, reduced ,atients admitted to intensi+e care units 2AB3 &Anaemia er$t!ro,oiesis, s!ortened and Blood %rans usion in 3ritical 3are' stud$4 5, t!e meanred blood cell sur+i+al le+el o !aemoglobin &6b' on admission 7as 113823 g9L &%able "'1;,11/ and 21: o t!e ,atients !ad a 6b concentration belo7 1;; #urgical bleeding ,la$s g9L/ %!e o+erall rate o trans usions during t!e admissions a )e$ role and is related to 7as 3<:, being !ig!er in ,atients admitted because o t!e t$,e o o,eration/ %!e surgical emergencies &5</5:' t!an in t!ose admitted AB3 stud$ s!o7ed t!at t!e because o trauma &4=:', electi+e surger$ &42/1:', or mean le+els o 6b on medical causes &32:'5/ #imilar results 7ere ound in an admission to intensi+e care analogous stud$ &3R"% stud$' carried out in t!e >#A in units 7ere lo7er in ,atients 2;;; on 4,=12 ,atients? t!e mean le+el o 6b at admission 7!o !ad undergone 7as 11;824 g9L, and t!e o+erall rate o trans usion 7as emergenc$ surger$ &1;= 44:</ A large, multicentre stud$ in #cotland in 2;;3 g9L' t!an in t!ose 7!o !ad s!o7ed t!at at t!e time o disc!arge rom t!e intensi+eundergone electi+e surger$ care units @ust under 1;: o t!e ,atients 7ere anaemic&11; g9L' or trauma &115 &6b A13; g9L in males and A115 g9L in emales' and about g9L' or 7!o !ad medical 5;: !ad a 6b concentration belo7 1;; g9L=/ disorders &111 g9L'/ Post. %!e im,act o anaemia in ,atients during t!e ,ost. o,erati+e blood losses can o,erati+e ,eriod and its o,timal treatment !a+e not been be signiBcant, ,articularl$ clearl$ deBned and t!ere are no uni+ersall$ acce,ted in cases o cardio+ascular Ctrans usion t!res!oldsC/ "n t!ese ,atients, man$and ort!o,aedic surger$5,12. 15 trans usions are ,robabl$ carried out on t!e /
+lood Transfus %/11$01*%/&*. DE" 32
F #"M%" #er+izi #rl

Table I - Possible causes o surger$.related anaemia in t!e ,ost.o,erati+e ,eriod/

Acute or chronic blood loss

1. 2. 3. 1. 2. 3.

"ntra.o,erati+e or ,ost. o,erati+e bleeding Re,eated sam,ling Gastrointestinal bleeding blood

Reduced erythropoiesis Reduced ,roduction o er$t!ro,oietin Resistance to action o er$t!ro,oietin iron Shortened red blood cell survival t!e

Reduced abilit$ to use


The "ost&o"erative "eriod

tests is a rele+ant cause o anaemia/ "t is estimated t!at,

Table II - #trategies t!at can be used to reduce t!e need or blood trans usions/

in t!e absence o s,eciBc measures, t!e mean dail$ blood loss ,er ,atient is about 4; mL and t!at u, to 3;: o trans usions gi+en in intensi+e care units are due to t!is cause1,5,1;,11,1<,1=/ Gastrointestinal bleeding, secondar$ to stress.related mucosal disease, is anot!er ,ossible cause o anaemia, e+en t!oug! its contribution is ,robabl$ o+erestimated/ #uc! bleeding !as man$ underl$ing mec!anisms, 7!ic! are not com,letel$ understood, and occurs in ;/2.5: o ,atients admitted to intensi+e care units/ #,eciBc ris) actors are res,irator$ ailure re-uiring +entilator$ assistance, clotting disorders, acute renal ailure, acute li+er ailure, se,sis, a !istor$ o gastrointestinal bleeding, and administration o !ig! doses o corticosteroids2,11.22/ 3oagulation disorders, suc! as t!romboc$to,enia, ,latelet unction de ects, clotting actor deBciencies and !$,erBbrinol$sis, are ,resent in man$ criticall$ ill ,atients in t!e ,ost.o,erati+e ,eriod and can 7orsen acute and c!ronic blood loss11,23/ Reduced er$t!ro,oiesis in criticall$ ill ,atients !as been re,orted in di erent studies and could be caused b$ +arious actors related to t!e inGammator$ state/ 6ig! concentrations o inGammator$ c$to)ines, suc! as tumour necrosis actor., interleu)in.1 and interleu)in. 5, are o ten ,resent in ,atients 7it! se,sis or ,atients 7!o !a+e undergone trauma and can cause a reduction in t!e ,roduction o er$t!ro,oietin or in!ibit er$t!ro,oiesis e+en in t!e ,resence o normal circulating concentrations o t!is !ormone1;,11,24.21/ %!e acute ,!ase in lammator$ res,onse can also modi $ iron metabolism and com,romise t!e o,timal use o t!is element b$ t!e bone marro7, leading to inade-uate er$t!ro,oiesis or t!e degree
o anaemia1;,11,3;.32/

1. 2. 3. 4. 5. 5.

3onstant monitoring o t!e criticall$ ill ,atient Pro,!$laHis against gastrointestinal bleeding Limitation o iatrogenic blood losses E,timisation o oH$gen release to tissues 3ontainment o oH$gen consum,tion b$ tissues E,timisation o er$t!ro,oiesis

o com,lement/ %!ere is no e+idence o s!ortened er$t!roc$te sur+i+al in ot!er situations1;,11,33,34/

Prevention of anaemia
%!e eH,ansion o ,lasma +olume ollo7ing administration o luids can simulate a state o anaemia and, 7!en e+aluating t!e ,atientIs clinical and biological ,arameters, t!e t7o conditions s!ould be di erentiated &Grade of recommendation1 13J'1;/ %!e strategies t!at can be used to ,re+ent anaemia and, t!ereb$, reduce t!e need or trans usion o allogeneic blood com,onents, are listed in %able

#!ortened er$t!roc$te sur+i+al can contribute to t!e anaemia t!at occurs in t!e ,ost.o,erati+e ,eriod in some criticall$ ill ,atients/ %!e use o cardio,ulmonar$ b$,ass or !eart surger$ and +al+e re,lacements can bot! lead to a +ariable degree o !aemol$sis/ #ome ,rocedures, ,articularl$ t!ose t!at cause tissue damage, induce oHidati+e stress 7it! release o radicals ca,able o com,romising t!e integrit$ o t!e red cell membrane/ Premature destruction o red blood cells can occur in criticall$ ill ,atients 7it! s$stemic inGammator$ res,onse s$ndrome &#"R#' or se,sis because o t!e acti+ation

3onstant monitoring o t!e criticall$ ill ,atient is o !el, in ,re+enting bleeding and treating e,isodes o !aemorr!age/ %!e Brst measure consists in ,rom,tl$ identi $ing and treating an$ clotting disorders/ Bleeding must be treated ra,idl$, be ore t!e ,atientIs ,!$siological reser+es are eHcessi+el$ reduced/ A,,ro,riate surgical inter+entions can be used in t!e ,resence o localised bleeding &Grade of recommendation1 23'K angiogra,!icall$ guided embolisation can be a use ul strateg$35.3</ "n t!e case o uncontrolled bleeding, a state o mild or moderate !$,otension can be establis!ed t!roug! restriction o in used GuidsK t!e blood ,ressure must be controlled +er$ care ull$ and restored to normal +alues as soon as t!e bleeding is !alted & Grade of recommendation1 23'35.3</ (!en t!e bleeding is generalised or its site cannot be reac!ed, t!e use o !aemostatic agents suc! as traneHamic acid s!ould be considered &Grade of recommendation1 23J'3=.42/ Pro,!$laHis against gastrointestinal bleeding, 7it! antacids, sucral ate, 6 rece,tor antagonists, or ,um, in!ibitors, is @ustiBed 2in ,atients at t!e !ig!est ris), in ,articular t!ose undergoing mec!anical +entilation or

more t!an 4= !ours and t!ose 7it! altered blood

+lood Transfus 1;/245;92;11/;;<5. %/11$01*%/&*. DE" 1; 32!

2iumbruno GM et al3

coagulationK at ,resent t!ere is no e+idence in a+our o t!e routine use o t!ese drugs in all ,atients in t!e ,ost. o,erati+e ,eriod &Grade of recommendation1 13J'43.4=/ %!e aim o minimising iatrogenic blood loss s!ould be ,ursued b$ onl$ carr$ing out essential laborator$ tests, 7it!dra7ing onl$ t!e strictl$ necessar$ amount o blood, ,er orming multi,le tests on a single blood sam,le, using de+ices to minimise unnecessar$ blood losses and im,lementing s,eciBc guidelines & Grade of recommendation1 23J'2,1,41.52/ E,timisation o oH$gen release to t!e tissues can be a+oured b$ t!e maintenance o an ade-uate cardiac out,ut and t!e use o oH$gen t!era,$/ Limiting oH$gen consum,tion b$ tissues can be ac!ie+ed, 7!en re-uired, b$ using analgesics, sedati+es, muscle relaHants and mec!anical +entilationK induction o mild or moderate !$,ot!ermia ma$ sometimes be a,,ro,riate, in t!e absence o coagulation disorders &Grade of recommendation1 23'35,53/ E,timisation o er$t!ro,oiesis can be ,ursued b$ using iron and er$t!ro,oietin/ Fe7 studies !a+e e+aluated t!e use o iron 7it!out associated er$t!ro,oietin in t!e ,ost.o,erati+e ,eriod/ E+erall, t!e beneBt a,,ears modestK based on results rom obser+ational studies, intra+enousl$ administered iron can reduce trans usion re-uirements in ,atients undergoing ort!o,aedic surger$, but not in t!ose undergoing cardio+ascular surger$54,55/ "n contrast, numerous studies !a+e e+aluated t!e use o iron in combination 7it! er$t!ro,oietin/ "n one randomised stud$ o 1,3;3 ,atients, er$t!ro,oietin &4;,;;; >" subcutaneousl$, once a 7ee), or t!ree consecuti+e administrations' in combination 7it! iron &15; mg o elemental iron eac! da$, administered orall$ or ,arenterall$' led to a signiBcant reduction in trans usion needs, 7it!out eH,osing t!e ,atients to t!e ris) o se+ere ad+erse reactions, suc! as t!romboembolic com,lications, allergies, or ,ure red cell a,lasia/ %!ese results !a+e been conBrmed b$ numerous subse-uent studies1;,11,24,21,55.51/ Alt!oug! it !as been clearl$ demonstrated t!at er$t!ro,oietin can reduce trans usion needs in criticall$ ill ,atients, it remains to be demonstrated 7!et!er t!is !as a clinical beneBt, in ,articular in terms o reducing mortalit$, morbidit$ and duration o admission, and 7!et!er it decreases costs/ 3onse-uentl$, er$t!ro,oietin can be used in sub@ects 7!o re use

trans usion or in selected ,atients, suc! as t!ose 7it! com,leH immuno!aematological ,roblems, 7it! renal ailure or c!ronic anaemia, ,er!a,s combined 7it! oral or ,arenteral iron t!era,$ &Grade of recommendation 23J'21,55.51/ 6o7e+er, ,rescri,tions o er$t!ro,oietin , and z are currentl$ ,aid or b$ t!e Lational 6ealt! #er+ice onl$ i t!e !ormone is used to increase t!e amount o autologous blood in t!e setting o ,rede,osit ,rogrammes, 7it! t!e limitations set out in t!e ,roduct summar$ leaGet/ "n addition to er$t!ro,oietin , and z, darbe,oetin can also be ,rescribed or t!e treatment o anaemia in ,atients 7it! c!ronic renal ailure/ Furt!er studies are necessar$ to e+aluate t!e use ulness o routine administration o er$t!ro,oietin to all ,atients in t!e ,ost.o,erati+e ,eriod/

Transfusion therapy
Post.o,erati+e trans usion su,,ort is aimed at correcting anaemia and treating secondar$ coagulation disorders, t!roug! t!e use o t!e ollo7ing blood com,onents? allogeneic red cell concentrates &R33', autologous 7!ole blood or blood com,onents, ,latelet concentrates and res!. rozen ,lasma &FFP'52.55/ "lood components that can be used As a guide, one unit o R33 increases t!e 6b b$ 1; g9L and t!e !aematocrit &6tc' b$ about 3: in adultsK in c!ildren, t!e trans usion o 5 mL9)g leads to an increase in t!e 6b o about 1; g9dL/ " t!e increases are less t!an eH,ected, t!e ,resence o detrimental conditions, suc! as continued blood loss or se-uestration or destruction o red blood cells, must be e+aluated55,5</ Autologous blood com,rises units o 7!ole blood or R33 obtained b$ ,re.o,erati+e donation o autologous blood, acute normo+olaemic !aemodilution, intra. o,erati+e blood sal+age or ,ost.o,erati+e blood sal+age &PEB#'/ Platelet concentrates can be obtained rom a donation o 7!ole blood or b$ a,!eresis/ %!e initial dose to be trans used can be calculated using a,,ro,riate ormulaeK it is essential to monitor t!e e Bcac$ o t!e trans usion in order to !a+e a guide or ,ossible subse-uent ,latelet trans usions55,5=/ FFP can be obtained rom units o 7!ole blood or collected b$ a,!eresis, %!e recommended initial dose o FFP is 1;.15 mL9)g o bod$ 7eig!t/ #ubse-uent
+lood Transfus

%/11$01*%/&*. DE"

1;/245;92;11/;;<5 .1;

The "ost&o"erative "eriod


Lactate acidosis &lactates M2 mmol9L J acidosis'

doses de,end on t!e ,atientIs clinical condition, as determined b$ regular monitoring, and laborator$ results55,5=/

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;

Transfusion practice
%!e ,at!o,!$siological mec!anisms underl$ing t!e need or trans usion o red blood cells, as 7ell as t!e clinical, instrumental and laborator$ ,arameters, !a+e alread$ been described in t!e recommendations on intra. o,erati+e trans usion &Blood %rans us 2;11K #?1=1.21<'/ Also in t!e ,ost.o,erati+e ,eriod, t!e indication or trans usion o red blood cells and t!e urgenc$ o t!e trans usion must be determined based on a com,lete e+aluation o t!e ,atientIs clinical condition &%able """', an assessment o t!e d$namics o !aematological ,arameters &6b and 6tc' and laborator$ and instrumental ,arameters indicati+e o inade-uate ,er usion and oH$genation o +ital organs
&%able "*'52,55,5<,51.=;/ Table III - 3linical ,arameters to e+aluate or trans usion ,ur,oses/
Age #igns and s$m,toms o anaemia #,eed o blood loss Amount o blood loss 3ardiac unction Lung unction "sc!aemic !eart disease Drug treatments

Table I$ - 3linical and instrumental ,arameters indicati+e o !$,oHia in t!e anaemic, normo+olaemic ,atient in t!e ,ost.o,erati+e ,eriod/
%ardiopulmonary symptoms

1. 2. 3. 4. 1. 2. 3.

%ac!$cardia 6$,otension Acute !$,otension o un)no7n origin D$s,noea

&lectrocardiographic signs typical of ischaemia Le7l$ occurring #% segment ele+ation or de,ression Enset o arr!$t!mias t!e

Le7l$ occurring localised altered contractilit$ o m$ocardium

'lobal indices of insuf(cient )2 release* evaluated by invasive methods

1. 2.

"ncrease in o+erall E2 eHtraction greater t!an 5;: Reduction o E2 u,ta)e b$ more t!an 1;: o t!e initial Reduction o miHed +enous E2 saturation to belo7 5;: Reduction o ,eri,!eral miHed +enous ,E 2 to belo7 32 Reduction o central +enous E2 saturation to belo7 5;:

3. 4.


Transfusion of autologous +hole blood or red cell concentrates

"n t!e ,resence o acute anaemia, t!e main t!era,eutic strateg$ is to ,re+ent or correct !$,o+olaemic s!oc) b$ in using su Bcient amounts o cr$stalloids9colloids to maintain t!e blood Go7 and ,ressure/ %!e c!aracteristics o t!e cr$stalloid and colloid solutions to trans use and t!eir mode o use !a+e alread$ been described in t!e recommendations on intra. o,erati+e trans usion &Blood %rans us 2;11K #?1=1.21<' &Grade of recommendation1 1('55/ %!e decision to trans use R33 or 7!ole blood de,ends on t!e amount o t!e blood loss, t!e 6b concentration and t!e ,atientIs clinical condition &tables * and *"'/ A loss o less t!an 15: o t!e blood +olume does not usuall$ ,roduce s$m,toms or re-uire trans usion, ,ro+iding t!ere is not ,re.eHisting anaemia &Grade of
recommendation1 1C4'35.3=,52,55,5<,<5,=1.1;/

(!en t!ere is a loss o bet7een 15: and 3;: o t!e blood +olume, com,ensator$ tac!$cardia occurs and t!e trans usion o R33 is indicated onl$ in t!e ,resence o ,re.eHisting anaemia or concomitant cardio,ulmonar$ disease &Grade of recommendation1

Blood losses o more t!an 3;: can cause s!oc) and, 7!en t!e blood loss eHceeds 4;:, t!e s!oc) becomes se+ere/ %!e ,robabilit$ o !a+ing to use trans usion t!era,$ 7it! R33 increases notabl$ 7it! losses o 3;. 4;:, e+en t!oug! +olume re,lacement alone ma$ be su Bcient in ,re+iousl$ !ealt!$ sub@ects &Grade of recommendation1 1C4'35.3=,52,55,5<,<5,=1.1;/ %rans usion becomes a li t!era,$ 7!en more t!an 4;: o t!e ,atientIs blood is lost &%able



&Grade of recommendation1 1C4'35.3=,52,55,5<,<5,=1. / Patients 7it! 6b +alues belo7 5; g9L almost al7a$s

re-uire trans usion t!era,$/ "n stable ,atients 7it! 6b +alues bet7een 5; and 1;; g9L, an e+aluation o t!e ,atientsI clinical status is necessar$, 7!ile ,atients 7it! +alues o+er 1;; g9L +er$ rarel$ need trans usion & Grade of recommendation1 1C4'35.3=,52,55,5<,<5,=1.12/ "t s!ould be remembered t!at ,atients 7it! acute bleeding can !a+e normal, or e+en raised, +alues o 6tc, until t!e ,lasma +olume is restoredK t!e clinical e+aluation o t!e ,atient in t!is situation is, t!ere ore, eHtremel$ im,ortant &%able *"' &Grade of
recommendation1 %C4'35.3=,52,55,5<,<5,=1.12/

"n anaemic ,atients 7!o do not !a+e ongoing

2iumbruno GM et al3

Table $ - Decision criteria or t!e trans usion o ,atients 7it! acute ,ost.o,erati+e anaemia? reduction o +olaemia
"lood loss ,m-./ A<5; <5;. 1,5;; 1,5;;. 2,;;; M2,;;; ' o R
e s s a r $ L e c e s s n e c a r $

%lass of haemorrhage 3lass " 3lass "" 3lass """ 3lass "*

Reduction of volaemia ,0. A15: 15.3;: 3;.4;: M4;:

Indication for transfusion of R%% Lot necessar$, unless ,re. eHisting anaemia Lot necessar$, unless ,re. eHisting anaemia and9or cardio,ulmonar$ disease
P r o b a b l $

1 3 1 3 1 3 1 3

Legend? R33? red cell concentrateK GoR? Grade o recommendationK N? in an adult 7eig!ing <; )g 5;.=; g9L 7it! an intra+ascular blood +olume o 5,;;; mL/

ade-u Absence o ris) actors9ade-uate mec!anisms o com,ensation ate Presence o ris) actors &e/g/ coronar$ arter$ disease, !eart ailure, cerebro+ascular disease9 indica limited mec!anisms tor o o com,ensation' a Presence o s$m,toms indicati+e o !$,oHia &,!$siological trans usion triggers? tac!$cardia, ,erso !$,otension, electrocardiogra,!ic signs o isc!aemia, lactic acidosis, etc/' nOs =;.1;; ca,ac Table $I - Decision criteria or t!e g9L Presence o s$m,toms indicati+e o !$,oHia &,!$siological trans usion triggers? tac!$cardia, it$ to trans usion o ,atients 7it! acute ,ost. releas !$,otension, electrocardiogra,!ic signs o isc!aemia, lactic acidosis, etc/' o,erati+e anaemia e E2 %% is +er$ rarel$ needed M1;; g9L to t!e 4otes5 tissue s/ 1b value Presence of ris2 factors3mechanisms 1. of compensation %!e 6b +alue is not an 2. N %% is almost al7a$s necessar$ 5; g9L

cause a signiBcant blood loss t!e criteriaincrease re,orted in %able *" can be in used/ Lumerous studiesmortalit$, !a+e s!o7n t!at in suc!cardiac ,atients t!ere is nomorbidit$ signiBcant di erence inor mortalit$ at 3; da$s 7!et!erduration a restricti+e trans usiono ,olic$ or a liberal!os,ital trans usion ,olic$ is usedsta$/ Ene &t!res!old !aemoglobin,ossible concentration or orderingeHce,tion trans usion o <;.=; g9dL oris t!e about 1;; g9dL,,atients res,ecti+el$'/ %!ere is7it! e+idence t!at a restricti+eunderl$in trans usion ,olic$ does notg

ca rdi o+ as cu lar di se as e & G ra de of # ec o m

indicated i must not be based t!e ,latelet is eHclusi+el$ on t!e ,latelet count count, but must also ta)e greater t!an 1 into account t!e ,atientIs 1;;H1; 9L, it clinical condition &in 7!ile seems ,articular a bod$ tem,erature abo+e 3=/5 P3, necessar$ i t!e count is ,lasma coagulation belo7 disorders, recent 1 !aemorr!ages and 5;H1; 9L and t!ere is neurological deBcits' ongoing &Grade of eHcessi+e bleeding recommendation1 %C' 35,3=,52,5=,=3,=5,=1,1;,1;1.1;4/ &Grade of "n t!e ,ost.o,erati+erecommend ,atient 7it! normal ,latelet ation1 %C' unction, trans usion o 35,3=,52,5=,=3,=5,=1,1 ,latelet concentrates is rarel$;,1;1.1;4/

"n cases o intermediate ,latelet counts &bet7een 5;H1;19L and 1;;H1;19L', a trans usion must be considered in s,eci ic circumstanc es, including ,latelet d$s unction, a !ig! ris) o bleeding

and a ris)
+lood Transfus %/11$01*%/& *. DE"


The "ost&o"erative "eriod

7it! correction o t!e underl$ing cause &Grade of

o bleeding into critical sites suc! as t!e e$es and brain

&Grade of recommendation1 %C'

recommendation1 1C4'35,3=,52,55,5=,=3,=5,=1,1;,1;5,111.131/

"n t!e case o ,latelet unction de ects, 7!et!er congenital or ac-uired &e/g/ due to anti,latelet drugs, cardio,ulmonar$ b$,ass', ,latelet trans usions are indicated, inde,endentl$ o t!e35,3=,52,5=,=3,=5,=1,1;,1;1. ,latelet count, in t!e ,resence o ,eri.o,erati+e bleeding not related to t!e surger$ or ot!er clotting disorders &Grade of recommendation1 %C'

"n t!e case in 7!ic! t!e P% and aP%% cannot be obtained in a reasonable time, a trans usion o FFP can be gi+en in an$ case in an attem,t to sto, t!e micro+ascular bleeding due to t!e coagulation de ect
&Grade of recommendation1 1C4'35,3=,52,55,5=,=3,=5,=1,1;,111.131/

3 "n ,atients 7it! acute disseminated intra+ascular coagulation &D"3' 7!o !a+e substantial bleeding and t!romboc$to,enia, ,latelet trans usion ma$ be indicated to maintain t!e ,latelet count around 5;H1; 19L &Grade of recommendation1 %C'1;5/ "n ,atients 7it! D"3 7!o are not bleeding, ,ro,!$lactic trans usion o ,latelet concentrates is reser+ed to t!ose cases in 7!ic! t!e t!romboc$to,enia and stratiBcation o bleeding ris) suggest a !ig! ,robabilit$ o bleeding &Grade of recommendation1 %C' / (!en t!e t!romboc$to,enia is due to increased ,latelet destruction &!e,arin.induced t!romboc$to,enia, autoimmune t!romboc$to,enia, t!rombotic t!romboc$to,enic ,ur,ura' ,ro,!$lactic ,latelet trans usion is ine ecti+e and rarel$ indicated
&Grade of recommendation1 %C'35,3=,52,5=,=3,=5,=1,1;,1;1.1;33

%!e recommended initial dose o FFP is 1;.15 mL9)g o bod$ 7eig!t/ %!e ,atientIs clinical condition and laborator$ ,arameters s!ould be monitored as t!ese ma$ @usti $ t!e administration o !ig!er doses &u, to 3; mL9)g' o FFP &Grade of recommendation1

FFP is not recommended or t!e correction o congenital or ac-uired deBciencies o clotting actors in t!e absence o bleeding, nor or t!e correction o deranged !aemostasis in ,atients 7it! acute or c!ronic li+er disease 7!o do not bleed &Grade of
recommendation1 1C4'35,3=,52,55,5=,=3,=5,=1,1;,111.131/

Autotransfusion +ith post-operative salvaged blood

The rationale of post-operative blood salvage %!e trans usion o allogeneic R33 is undoubtedl$ e ecti+e, but eH,oses ,atients to t!e ris), albeit limited, o ad+erse reactions t!at include in ectious diseases and ,ossible immunode,ression, 7it! a conse-uent increase in t!e ,ossibilit$ o ,ost.o,erati+e in ections132.13</ Autotrans usion 7it! ,ost.o,erati+el$ sal+aged blood is, t!eoreticall$, a sim,le and economic met!od o reducing t!e use o allogeneic bloodK its utilit$ in electi+e o,erations, in ,articular or ort!o,aedic and !eart surger$, !as been re,orted in numerous studies, most o 7!ic! 7ere, !o7e+er, conducted in limited numbers o ,atients/ Absolute contraindications to t!e use o t!is ,rocedure are bacterial contamination o t!e surgical Beld and !aematological disorders t!at en!ance t!e l$sis o red blood cells, suc! as t!alassaemia and sic)le cell anaemia &Grade of recommendation1 1C4'13=/

"n ,atients 7!o are anaemic and t!romboc$to,enic &,latelet count 2;H1;19L', but not acti+el$ bleeding, an increase in t!e 6tc to around 3;: can reduce t!e ris) o !aemorr!age &Grade of recommendation1

%!e ,latelet count s!ould be measured be ore, 1 !our a ter and 2;.24 !ours a ter t!e trans usion o t!e ,latelet concentrate and t!e corrected count increment s!ould be calculated &Grade of recommendation1 1C4'5=/ %rans usion o FFP is indicated or t!e correction o congenital de iciencies o clotting actors or 7!ic! a s,eciBc concentrate does not eHist, and or multi,le ac-uired deBciencies o suc! actors &acute or c!ronic li+er disease', 7!en t!e ,rot!rombin time &P%' or acti+ated ,artial t!rombo,lastin time &aP%%', eH,ressed as a ratio, is greater t!an 1/5, in t!e ,resence o bleeding not related to t!e surger$ &or to ,re+ent it, in t!e case o congenital actor deBciencies in t!e absence o t!e s,eciBc concentrates', micro+ascular bleeding in ,atients undergoing massi+e trans usion, acute D"3 in t!e ,resence o ongoing bleeding, toget!er

7evices for post-operative blood salvage PEB# consists in collecting, into an a,,ro,riate container, t!e blood t!at a ,atients loses t!roug! surgical drains, and subse-uentl$ rein using t!e blood bac) into t!e ,atient/ %7o s$stems can be used or
+lood Transfus 1;/245;92;11/;;<5 %/11$01*%/&*. DE".1;

2iumbruno GM et al3

t!is ,rocedure? Cun7as!edC and C7as!edC s$stems/ "n t!e un7as!ed s$stem t!e blood is trans used rom t!e container connected to t!e drains to t!e in usion set and is rein used 7it!out undergoing treatment/ %!e blood is ,assed t!roug! t7o ilters, t!e Brst 7it! a mes! o 1;;.2;; to retain Bbrin and macroaggregates and a second one 7it! a 4; mes! to tra, microaggregates/ Anticoagulation is not necessar$ since t!e blood does not contain Bbrinogen/ %!is s$stem in+ol+es sim,le, economic and eas$ to use e-ui,ment/ "n t!e 7as!ed s$stem s,eciBc e-ui,ment is used to centri uge t!e collected blood, eliminate t!e su,ernatant, 7as! t!e red blood cells and resus,end t!em in saline solution/ %!is s$stem is more eH,ensi+e and t!e sta using it re-uire care ul training131/ %haracteristics of blood collected in the post-operative period Blood collected b$ PEB# is not identical to +enous blood in t!at it is diluted and contains li,id ,articles, bone ragments, ree 6b and a series o bioacti+e contaminants suc! as acti+ated clotting actors, Bbrin degradation ,roducts, and inGammator$ mediators &%able *""'K t!ese substances can be res,onsible or numerous ad+erse reactions/ >n7as!ed blood !as a 6tc bet7een 2;.3;:

and lo7er le+els o 6b, red blood cells, ,latelets and leucoc$tes com,ared to t!e le+els in +enous blood/ %!is is a result o !aemodilution, Bltration and a certain degree o !aemol$sis, as demonstrated b$ t!e increase in ree 6b and cellular debris/ "t is t!oug!t t!at ree 6b ma$ be res,onsible or renal damageK urt!ermore, er$t!roc$te stroma ma$ !a+e a ,rocoagulant action, leading to D"3/ %!e undamaged er$t!roc$tes do not seem to !a+e mor,!ological or unctional abnormalities and !a+e normal energ$ metabolism and +iabilit$131.142/ Follo7ing acti+ation o coagulation and ibrinol$sis, un7as!ed blood contains acti+ated clotting actors and Bbrinogen degradation ,roducts, 7!ereas it lac)s actor *, actor *""", antit!rombin, Bbrinogen, ,rotein 3 and ,lasminogen/ Rein usion o t!is blood can lead to bot! t!rombotic and !aemorr!agic c!anges in 131,14;,142.144 coagulation /
>n7as!ed blood also contains large amounts o bioacti+e contaminants suc! as c$to)ines and ana,!$latoHins deri+ing rom t!e degranulation o ,latelets and leucoc$tes, and rom t!e acti+ation o com,lement and t!e inGammator$ cascade/ %!ese substances can cause ad+erse reactions suc! as e+er, tac!$cardia, !$,otension, altered immune status, or se+ere ad+erse reactions related to damage to t!e microcirculation, suc! as acute res,irator$ distress s$ndrome, #"R#, and multiorgan ailure


Table $II 3!aracteristic s o ,ost. o,erati+e sal+aged blood/

1aematologic al and biochemical parameters R B 3 , 6 b , 6

c ,

( B 3

r e e

, P

6 b , L D 6 , Q

L % RB3? M3*, 2,3.DPG, A%P "ioactive contaminants A c t i + a t

i o n o

, F G

Platelet degranulation? serotonin, !istamine, PA".1, %HA2, %HB2, PF4 Leucoc$t e degranula tion? "L. 1, "L. 5, "L. =, %LF. , elastases , 0PR, MPR, PG02, 03P, PG"2, leucotrien es 3om,lem ent acti+ation

c o a g u l a t i o n ? F R " " a , F R " " " a , F * , F * " " " ,

A c t i + a t i o n o

B b r i n o l $ s i s ? F D P , D . d i m e r , t

? 31, 33, 35, 33a, 35a Acti+ation o inGammation? ree radicals, endot!elin, ,!o,!oli,ase A2, microaggregates Legend? 2,3.DPG? 2,3. di,!os,!ogl$cerateK A%? antit!rombinK A%P? adenosine tri,!os,!ateK 31, 33, 35? com,lement com,onents 1, 3 and 5K 33a, 35a? acti+ated com,lement com,onents 3 and 5K 03P? eosino,!il cationic ,roteinK 0PR? eosino,!il ,rotein RK FDP? Bbrinogen degradation ,roductsK FG? BbrinogenK F*? actor *K F*"""? actor *"""K FR""a? acti+ated actor R""K FR"""a? acti+ated actor R"""K 6b? !aemoglobinK 6tc? !aematocritK "L.1? interleu)in 1K "L.5? interleu)in 5K "L.=? interleu)in =K QJ? ,otassium ionsK LD6? lactate de!$drogenaseK M3*? mean cor,uscular +olumeK MPR? m$elo,eroHidaseK PA".1? ,lasminogen acti+ator in!ibitor t$,e 1K PF4? ,latelet actor 4K PG02? ,rostaglandin 02K PG"2? ,rostaglandin "2K PL%? ,lateletsK RB3? red blood cellsK %LF. ? tumour necrosis actor K tPA? tissue ,lasminogen acti+atorK %HA2? t!romboHane A2K %HB2? t!romboHane B2K (B3? 7!ite blood cellsK ? increasedK ? decreasedK ? unc!anged/

A %


+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;


The "ost&o"erative "eriod

"t !as been demonstrated t!at t!e abo+e listed contaminants are not onl$ ,resent in un7as!ed blood collected ,ost.o,erati+el$, but are also ,resent in t!e ,atient 7!o recei+es t!is blood/ %!ere !a+e been numerous re,orts o se+ere, and sometimes e+en atal, com,lications/ %!e sa et$ o un7as!ed blood is still sub@ect o discussion, alt!oug! most o t!e numerous studies carried out !a+e re,orted a limited number o se+ere com,lications35,15;/ "n order to im,ro+e t!e -ualit$ o un7as!ed blood and reduce t!e ris) o ,otential ad+erse reactions, t!e ollo7ing strategies !a+e been ,ro,osed? limiting t!e ,eriod o collecting t!e blood & or a maHimum 5 !ours rom t!e end o t!e o,eration', limiting t!e amount o blood rein used &total +olume rein used? less t!an 1,;;; mL', sedimentation o t!e ,roduct or 2; minutes ollo7ing its collection and elimination o t!e su,ernatant12,35,1;,131,151/ >n7as!ed blood is, !o7e+er, a ,roduct 7it! a +er$ +ariable -ualit$, 7!ic! is generall$ ,oor and does not con orm 7it! t!e standards o modern trans usion medicineK its use in t!e conteHt o PEB# ,rogrammes is not considered su Bcientl$ sa e and e ecti+e and does not seem ad+antageous rom an economic ,oint o +ie7 &Grade of recommendation1
1C J'35,15;/

anal$sed in a 3oc!rane meta.anal$sis in 2;;5 in 7!ic! it 7as concluded t!at t!e use o PEB# reduces t!e ,ercentage o ,atients 7!o re-uire trans usion o allogeneic blood and also t!e amount o allogeneic blood trans used13=/ %!e e Bcac$ o t!e ,rocedure is greater in ort!o,aedic surger$ t!an in !eart surger$, 7it! t!e mean reduction in t!e ris) o eH,osure to allogeneic blood being 5=: and 23:, res,ecti+el$/

"n t!e case o t!e 7as!ed s$stem, t!e blood is centri uged and 15.11: o t!e su,ernatant is remo+edK t!e red blood cells are 7as!ed and t!en resus,ended in saline/ %!e 7as!ed blood is a concentrate o normall$ unctioning, +iable red blood cells 7it!out bioacti+e contaminants/ %!is ,roduct con orms 7it! trans usion medicine standards, a,,ears to be e ecti+e, does not eH,ose t!e reci,ient to t!e ris) o ad+erse reactions and, i used in t!e ,resence o substantial loss o blood, can be ad+anrageous rom an economic ,oint o +ie7 &Grade of recommendation1 1C J'145,14=,152.155/ &fficacy of post-operative blood salvage in orthopaedic and cardiovascular surgery #ince t!e 111;s numerous studies !a+e been ,ublis!ed on PEB# in ,atients undergoing electi+e ort!o,aedic or cardio+ascular surger$/ Most o t!ese studies 7ere retros,ecti+e and alt!oug! t!ere !a+e been a e7 randomised studies, t!ese usuall$ in+estigated limited numbers o ,atients and ,roduced notabl$ !eterogeneous results &%ables *""" and "R'155.2;5/ %!e results o t!e randomised studies 7ere

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5 .1;

%!ere is little di erence bet7een t!e use o 7as!ed and un7as!ed blood in ort!o,aedic surger$, 7!ereas un7as!ed blood seems to be onl$ marginall$ e ecti+e in !eart surger$/ %!e use o PEB# does not seem to cause a signi icant increase in se+ere ,ost.o,erati+e com,lications &t!rombosis, in ections, renal ailure, m$ocardial in arction, need or re,eat surger$ because o bleeding', an increase in t!e time s,ent in !os,ital, or an increase in mortalit$/ %!e aut!ors did, !o7e+er, !ig!lig!t t!e limitations o t!e studies eHamined &small
Table $III - 3!aracteristics o t!e randomised, controlled studies? ort!o,aedic surger$/
Type of Authors :e ar operation Lorentz et al3155 #lagis et al3

4. of patient s enrolle d 54 1;1 42 5; 11 <3 45 1;; 231 31= 4; 231 =1 111 12= 5; 3; 24 232 <= <; 1;

Type of blood transfused 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed 7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed

Menges et al315= Qoo,man et al3151 Ma! et al3


Rollo et al31<1 0)bac) et al31<2 #!enoli)ar et al31<3 %!omas et al31<4 3lar) et al31<5 Ma@o7s)i et al31<5 Gannon et al31<< 6eddle et al31<= Mauer!an et al31<1 6eal$ et al31=;

11 11 11 11 11 12 11 13 11 15 11 15 11 15 11 1< 2; ;1 2; ;5 11 11 11 11 11 12 11 13 11 14 11 14 11 14 11 14 11 15 11 15 11 1< 11 1=

!i, !i,9)nee !i, !i,9s,ine )nee !i, !i, )nee )nee !i,9)nee )nee )nee )nee )nee9!i, !i,9)nee9 s,ine s,ine )nee )nee9!i, !i, !i, )nee )nee

Riou et al31=1 Rosenc!er et al31=2 #im,son et al31=3 A$ers et al31=4 Rollo et al31=5 Le7man et al3 Adalbert! et al31=<


Table I< - 3!aracteristics o t!e randomised, controlled studies? !eart surger$/

:e ar Type of interventio n 4. of patient s enrolle d 113 1;; 1;; 4; 42 135 4; 5; 35 32 <5 =2 12; 1;5 42 112 11= 55 5; Type of blood transfuse d un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed 7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed un7as!ed 7as!ed un7as!ed 7as!ed un7as!ed 7as!ed un7as!ed

recommendation1 %C4'35,13=/ "n an$ case, it is recommended t!at 7as!ed blood is ,re erred in bot! ort!o,aedic surger$ and in an$ ot!er ,ossible Belds o use &Grade of


%!urer et al31== Dietric! et al31=1 Page et al311; 0ng et al3111 #!ir+ani


Le,ore et al3113 #c!onberger114 Laub et al3115 (ard et al3


11 <1 11 =1 11 =1 11 1; 11 11 11 12 11 13 11 13 11 13 11 14 11 14 11 15 11 15 11 15 11 15 11 11 2; ;; 2; ;3

3ABG 3ABG 3ABG and +al+es 3ABG 3ABG 3ABG and +al+es 3ABG 3ABG 3ABG and +al+es 3ABG and +al+es 3ABG 3ABG 3ABG 3ABG 3ABG and +al+es 3ABG and +al+es 3ABG and +al+es 3ABG

AH ord et al311< Bouboulis et al311= Fragnito et al3111 #c!midt et al32;; >ns7ort!. (!ite et al32;1 S!ao et al32;2 Dalr$m,le. 6a$ et al32;3 Martin et al32;4 Laumen)o et al32;5

2; S!ao et al32;5 ;3 3ABG Legend? 3ABG? coronar$ arter$ b$,ass gra ting

numbers o ,atients and !ig! !eterogeneit$ o results' and eH,ressed t!e !o,e or larger, met!odologicall$ rigorous, controlled studies13=/ En t!e basis o considerations related to e Bcac$, sa et$ and costs, t!e ,ractice o PEB# a,,ears to be @ustiBed in ma@or ort!o,aedic surger$ &re,lacement o !i, and )nee @oints, +ertebral column o,erations' 7!ile it does not seem use ul in !eart surger$ or +ascular surger$, eHce,t in selected cases & or eHam,le, in ,atients 7!o re use a trans usion or 7!o !a+e com,leH immuno!aematological ,roblems' &Grade of

2iumbruno GM et al3

recommendation1 1C4'145,14=,152.155/ Le+ert!eless, i un7as!ed blood is used, it is recommended t!at t!e concentration o ree 6b is assa$ed be ore rein using t!e blood, 7it! t!e aim o determining t!at t!e degree o !aemol$sis is less t!an ;/=: o t!e red cell mass contained in t!e ,roduct trans used into t!e ,atient & Grade of recommendation1 1C4'53.5</ "t is suggested t!at t!e ollo7ing ormula is used to calculate t!e ,ercentage !aemol$sis o t!e blood obtained b$ PEB# &Grade of recommendation1
&1;; T 6tcPEB#' H ree 6bPEB# 6aemol$sis &:' U total 6bPEB# Legend? 6tcPE#B? 6tc o t!e blood obtained b$ ,ost.o,erati+e sal+age/ Free 6bPE#B? ree 6b in t!e su,ernatant or t!e medium used to sus,end t!e red blood cells/
%otal 6bPE#B? total 6b in t!e sus,ension o red blood cells rom PE#B/

%!e PEB# ,rocedure s!ould, in an$ case, be reser+ed to o,erations 7!ic! in+ol+e t!e loss o more t!an 1;: o t!e total blood +olume in t!e ,ost.o,erati+e ,!ase &Grade of recommendation1
1C J'35,13=/

Finall$, it s!ould be em,!asised t!at t!e e Bcac$ o PEB# a,,ears to be greater in t!ose ,atients 7!ose ,re. o,erati+e 6b concentration is bet7een 12;.15; g9L &Grade of recommendation1 %C4'35,13=K t!e beneBt seems to be limited in ,atients 7it! a ,re.o,erati+e 6b greater t!an 15; g9L, in 7!om t!e ,robabilit$ o trans usion o allogeneic blood is lo7, and in ,atients 7it! a ,re.o,erati+e 6b belo7 12; g9L, in 7!om PEB# seems to be e ecti+e onl$ i used in combination 7it! ot!er measures aimed at ,re+enting or treating ,ost. o,erati+e anaemia/ Furt!ermore, in dail$ clinical ,ractice, t!e le+els o e Bcac$ and sa et$ o PEB# are ade-uate and com,arable to t!ose re,orted in clinical studies onl$ i t!e sta delegated to ,er orming t!e ,rocedure are trained continuousl$ &Grade of recommendation1

%!e ,rocess o de+elo,ing t!ese Recommendations, in con ormit$ 7it! t!e indications in t!e met!odological manual o t!e national ,rogramme or

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;


The "ost&o"erative "eriod

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;

guidelines &"stituto #u,eriore di #anitV, Agenzia ,er i #er+izi #anitari Regionali/ Programma Lazionale ,er le Linee Guida . Manuale Metodologico/ Milano, "talia? Arti GraBc!e Passoni srlK 2;;2/ A+ailable at? !tt,?99777/snlg.iss/it9cms9Bles9ManualeWPLLGW;/ ,d / Last accessed on? ;392592;1;', made use o s$stematic literature re+ie7s and u,dates o alread$ eHisting recommendations on t!e sub@ect/ %!e met!odolog$ used to determine t!e grades o recommendation dre7 on t!at ,resented at t!e 2;;4 3onsensus 3on erence o t!e American 3ollege o 3!est P!$sicians &Gu$att G, #c!Xnemann 6Y, 3oo) D, et al/ A,,l$ing t!e grades o recommendation or antit!rombotic and t!rombol$tic t!era,$/ 3!est 2;;4K !29? #1<1.=<'/ %!e recommendations are classiBed b$ grades, eH,ressed in Arabic numbers &!* 2', according to t!eir strengt!, and in letters &A* "* %', reGecting t!e t$,e o stud$ and e+idence ,ro+ided/


1' 2'

3or7in 6L, Parsonnet Q3, Gettinger A/ %rans usion in t!e "3>/ 3!est 1115K ! =? <5<.<1/


+on A!sen L, MXller 3, #er)e #, et al/ "m,ortant role o nondiagnostic blood loss and blunted er$t!ro,oietic res,onse in t!e anemia o medical intensi+e care ,atients/ 3rit 3are Med 1111K 2;? 253;.1/ Rao MP, Boralessa 6, Morgan 3, et al/ Blood com,onent use in criticall$ ill ,atients/ Anaest!esia 2;;2K 8;? 53;.4/ (als! %#, Lee RY, Maci+er 3R, et al/ Anemia during and at disc!arge rom intensi+e care? t!e im,act o restricti+e blood trans usion ,ractice/ "ntensi+e 3are Med 2;;5K 32? 1;;.1/ 3!o!an ##, McArdle F, Mc3lelland DBL, et al/ Red cell trans usion ,ractice ollo7ing t!e trans usion re-uirements in critical care &%R"33' stud$? ,ros,ecti+e obser+ational co!ort stud$ in a large >Q intensi+e care unit/ *oH #ang 2;;3K =6? 211.=/ *incent YL, Baron YF, Rein!art Q, et alK AB3 &Anemia and Blood %rans usion in 3ritical 3are' "n+estigators/ Anemia and blood trans usion in criticall$ ill ,atients/ YAMA 2;;2K 2==? 1411.5;</ 3or7in 6L, Gettinger A, Pearl RG, et al/ %!e 3R"% #tud$? anemia and blood trans usion in t!e criticall$ ill? current clinical ,ractice in t!e >nited #tates/ 3rit 3are Med 2;;4K 32? 31.52/ (als! %#, #ale! 0, Lee RY, et al/ %!e ,re+alence and c!aracteristics o anaemia at disc!arge !ome a ter intensi+e care/ "ntensi+e 3are Med 2;;5K 32? 12;5.13/ La,olitano LM/ #co,e o t!e ,roblem? e,idemiolog$ o anemia and use o blood trans usions in critical care/ 3rit 3are 2;;4K =? #1.=/ McLellan #A, Mc3lelland DB, (als! %#/ Anaemia

3' 4'




=' 1' 1;'

and red blood cell trans usion in t!e criticall$ ill ,atient/ Blood Re+ 2;;3K !;? 115.2;=/

res,onse is blunted in criticall$ ill ,atients/ "ntensi+e 3are Med 111<K 23? 151.52/


6obisc!.6agen P, (iedermann F, Ma$r A, et al/ Blunted


*an de (iel A/ Anemia in criticall$ ill ,atients/ 0ur Y "nter Med 2;;4K !8? 4=1.5/

er$t!ro,oietic res,onse to anemia in multi,l$ traumatized ,atients/ 3rit 3are Med 2;;1K 2#? <43.</

12' 13'

Martin Y, Robitaille D, Perrault LP, et al/ Rein usion o mediastinal blood a ter !eart surger$/ Y %!orac 3ardio+asc #urg 2;;;K !2 ? 411.5;4/ (idman Y, Yacobsson 6, Larsson #A, "sacson Y/ Lo e ect o drains on t!e ,osto,erati+e !ematoma +olume in !i, re,lacement surger$/ Acta Ert!o, #cand 2;;2K ;3? 525.1/ 0sler 3LA, Bla)e7a$ 3, Fiddian LY/ %!e use o a closed.suction drain in total )nee art!ro,last$/ Y Bone Yoint #urg Br 2;;3K =8? 215.</ Yo!ansson %, 0ng-uist M, Pettersson LG, Lisander B/ Blood loss a ter total !i, re,lacement/ A ,ros,ecti+e randomized stud$ bet7een 7ound com,ression and drainage/ Y Art!ro,last$ 2;;5K 2 ? 15<.<1/ Par)er MY, Li+ingstone *, 3li ton R, McQee A/ 3losed suction surgical 7ound drainage a ter ort!o,aedic surger$/ 3oc!rane Database #$st Re+ 2;;<K 3? 3D;;1=25/ 0zzie M0, Aberegg #Q, EIBrien YM/ Laborator$ testing in t!e intensi+e care unit/ 3rit 3are 3lin 2;;<K 23? 435. 55/ 3!ant 3, (ilson G, Friedric! YE/ Anemia, trans usion, and ,!lebotom$ ,ractices in criticall$ ill ,atients 7it! ,rolonged "3> lengt! o sta$? a co!ort stud$/ 3rit 3are 2;;5K ! ? R14;/ 3oo) DY, Fuller 6D, Gu$att G6, et al/ Ris) actors or gastrointestinal bleeding in criticall$ ill ,atients/ L 0ngl Y Med 1114K 33 ? 3<<.=1/ Pimentel M, Roberts D0, Bernstein 3L, et al/ 3linicall$ signiBcant gastrointestinal bleeding in criticall$ ill ,atients in an era o ,ro,!$laHis/ Am Y Gastroenterol 2;;;K #8? 2=;1.5/ Le7is YD, #!in 0Y, Metz D3/ 3!aracterization o gastrointestinal bleeding in se+erel$ ill !os,italized ,atients/ 3rit 3are Med 2;;;K 2=? 45.5;/ Fis!er L, Fis!er A, Pa+li P, Da+is M/ Perio,erati+e acute u,,er gastrointestinal !aemorr!age in older ,atients 7it! !i, racture? incidence, ris) actors and ,re+ention/ Aliment P!armacol %!er 2;;<K 28? 21<.3;=/ Le+i M, E,al #M/ 3oagulation abnormalities in criticall$ ill ,atients/ 3rit 3are 2;;5, ! ? 222/ *an ",eren 30, Gaillard 3A, Qraai@en!agen RY, et al/ Res,onse o er$t!ro,oiesis and iron metabolism to recombinant !uman er$t!ro,oietin in intensi+e care unit ,atients/ 3rit 3are Med 2;;;K 2=? 2<<3.=/ Qra te.Yacobs B/ Anemia o critical illness and er$t!ro,oietin deBcienc$/ "ntensi+e 3are Med 111<K 23? 13<.=/ Rogiers P, S!ang 6, Leeman M, et al/ 0r$t!ro,oietin

14' 15'


1<' 1='

11' 2;'

21' 22'

23' 24'

25' 25'

mec!anical +entilation/ L 0ngl Y Med 111=K 33=? <11.</


DeAngelo AY, Bell DG, Zuinn M*, et al/ 0r$t!ro,oietin res,onse in criticall$ ill mec!anicall$ +entilated ,atients? a ,ros,ecti+e obser+ational stud$/ 3rit 3are 2;;5K #? R1<2.5/ 3or7in 6L/ %!e role o er$t!ro,oietin t!era,$ in t!e criticall$ ill/ %rans us Med Re+ 2;;5K 2 ? 2<.33/ Biesma D6, *an de (iel A, Beguin [, et al/ Post. o,erati+e er$t!ro,oiesis is limited b$ t!e inGammator$ e ect o surger$ on iron metabolism/ 0ur Y 3lin "n+est 1115K 28? 3=3.1/ *an ",eren 30, Qraai@en!agen RY, Biesma D6, et al/ "ron metabolism and er$t!ro,oiesis a ter surger$/ Br Y #urg 111=K =8? 41.5/ Rodriguez RM, 3or7in 6L, Gettinger A, et al/ Lutritional deBciencies and blunted er$t!ro,oietin res,onse as causes o t!e anemia o critical illness/ Y 3rit 3are 2;;1K !9? 35.41/ %aba) 3, 0ugene Y, #temmer 0A/ 0r$t!roc$te sur+i+al ollo7ing eHtracor,oreal circulation/ A -uestion o membrane +ersus bubble oH$genator/ Y %!orac 3ardio+asc #urg 11=1K =!? 3;.3/ +an ",eren 30, +an de (iel A, de Bruin M, MarH YYM/ %otal !i, re,lacement surger$ does not inGuence RB3 sur+i+al/ %rans usion 2;;;K 6 ? 1235.=/ #,a!n DR, 3asutt M/ 0liminating blood trans usions/ Anest!esiolog$ 2;;;K #3? 242.55/ (aters Y6/ Perio"erative +lood Management3 ( Physician5s !andboo6/ 1st ed/ Bet!esda, Mar$land? AABBK 2;;5/ Goodnoug! L%, #!ander A/ Blood management/ Arc! Pat!ol Lab Med 2;;<K !3!? 515.<;1/ (orld 6ealt! Erganisation/ The Clinical Use of +lood !andboo63 Gene+a? (6EK 2;;5/ Le+$ Y6/ P!armacologic met!ods to reduce ,erio,erati+e bleeding/ %rans usion 2;;=K 6=? 31#.3=#/ Lau,acis A, Fergusson D/ Drugs to minimize ,erio,erati+e blood loss in cardiac surger$? meta. anal$ses using ,erio,erati+e blood trans usion as t!e outcome/ Anest! Analg 111<K =8? 125=.5</ (ells P#/ #a et$ and e Bcac$ o met!ods or reducing ,erio,erati+e allogeneic trans usion? a critical re+ie7 o t!e literature/ Am Y %!er 2;;2K #? 3<<.==/ 6enr$ DA, 3arless PA, MoHe$ AY, et al/ Anti. ibrinol$tic use or minimising ,erio,erati+e allogeneic blood trans usion/ 3oc!rane Database #$st Re+ 2;;<K 6? 3D;;1==5/ Zuenot YP, %!ier$ L, Barbar #/ (!en s!ould stress ulcer ,ro,!$laHis be used in t!e "3>\ 3urr E,in 3rit 3are 2;;1K !8? 131.43/ 3oo) DY, Ree+e BQ, Gu$att G, et al/ #tress ulcer ,ro,!$laHis in criticall$ ill ,atients? resol+ing discordant meta.anal$ses/ YAMA 1115K 2;8? 3;=.14/ 3oo) D, Gu$att G, Mars!all Y, et al/ A com,arison o sucral ate and ranitidine or t!e ,re+ention o u,,er gastrointestinal bleeding in ,atients re-uiring


Qantoro+a ", #+oboda P, #c!eer P, et al/ #tress ulcer

21' 3;'

31' 32'


34' 35' 35' 3<' 3=' 31' 4;'

41' 42'

43' 44' 45'

2iumbruno GM et al3 ,ro,!$laHis in criticall$ ill ,atients? a randomized controlled trial/ 6e,atogastroenterolog$ 2;;4K 8!? <5<. 51/


Qar)outi Q, Mc3lus)e$ #A, G!annam M, et al/ "ntra+enous iron and recombinant er$t!ro,oietin or t!e treatment o ,osto,erati+e anemia/ 3an Y Anaest!

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;



3onrad #A, Gabrielli A, Margolis B, et al/ Randomized, double.blind com,arison o immediate.release ome,razole oral sus,ension +ersus intra+enous cimetidine or t!e ,re+ention o u,,er gastrointestinal bleeding in criticall$ ill ,atients/ 3rit 3are Med 2;;5K 33? <5;.5/ #,irt MY/ #tress.related mucosal disease? ris) actors and ,ro,!$lactic t!era,$/ 3lin %!er 2;;4K 29? 11<.213/ Pilon 3#, Leat!le$ M, Renne RR%, et al/ Practice guideline or arterial blood gas measurement in intensi+e care unit decreases numbers and increases a,,ro,riateness o test/ 3rit 3are Med 111<K 28? 13;=. 13/ #olomon D6, 6as!imoto 6, Daltro$ L, et al/ %ec!ni-ues to im,ro+e ,!$siciansI use o diagnostic tests/ YAMA 111=K 2= ? 2;2;.</ *ersta,,en (6YM, +an der (ei@den %, #i@brandi@ Y, et al/ 0 ect o a ,ractice.based strateg$ on test ordering ,er ormance o ,rimar$ care ,!$sicians/ A randomized trial/ YAMA 2;;3K 2=#? 24;<.12/ Qum7ilaisa) Q, Loto A, #c!midt >6, et al/ 0 ect o laborator$ testing guidelines on t!e utilization o tests and order entries in a surgical intensi+e care unit/ 3rit 3are Med 2;;=K 39? 2113.1/ Qurz A/ %!ermal care in t!e ,erio,erati+e ,eriod/ Best Pract Res 3lin Anaest!esiol 2;;=K 22? 31.52/ Beris P, Mu]oz M, 0rce YG, et al/ Perio,erati+e anaemia management? consensus statement on t!e role o intra+enous iron/ Br Y Anaest! 2;;=K ! ? 511.5;4/ Lotebaert 0, 3!aun$ YM, Albert M, et al/ #!ort.term beneBts and ris)s o intra+enous iron? a s$stematic re+ie7 and meta.anal$sis/ %rans usion 2;;<K 4<? 11;5. 1=/ 3or7in 6L, Gettinger A, Pearl RG, et al/ 0 Bcac$ o recombinant !uman er$t!ro,oietin in criticall$ ill ,atients? a randomized controlled trial/ YAMA 2;;2K 2==? 2=2<.35/ Garc^a.0rce YA, 3uenca Y, Mu]oz M, et al/ Perio,erati+e stimulation o er$t!ro,oiesis 7it! intra+enous iron and er$t!ro,oietin reduces trans usion re-uirements in ,atients 7it! !i, racture/ A ,ros,ecti+e obser+ational stud$/ *oH #ang 2;;5K ==? 235.43/ Garc^a.0rce YA, 3uenca Y, Martinez F, et al/ Perio,erati+e intra+enous iron ,reser+e iron stores and ma$ !asten t!e reco+er$ rom ,ost.o,erati+e anaemia a ter )nee re,lacement surger$/ %rans us Med 2;;5K !9? 335.41/ 3uenca Y, Garc^a.0rce YA, Martinez F, et al/ Perio,erati+e intra+enous iron, 7it! or 7it!out er$t!ro,oietin, ,lus restricti+e trans usion ,rotocol reduce t!e need or allogeneic blood a ter )nee re,lacement surger$/ %rans usion 2;;5K 69? 1112.1/

4=' 41'

5;' 51'


53' 54'






The "ost&o"erative "eriod +lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1; 2;;5K 83? 11.1/


#il+er M, 3or7in MY, Bazan A, et al/ 0 Bcac$ o recombinant !uman er$t!ro,oietin in criticall$ ill ,atients admitted to a long.term acute care acilit$? a randomised, double.blind, ,lacebo.controlled trial/ 3rit 3are Med 2;;5K 36? 231;.5/ American #ociet$ o Anest!esiologists %as) Force on Perio,erati+e Blood %rans usion and Ad@u+ant %!era,ies/ Practice guidelines or ,erio,erati+e blood trans usion and ad@u+ant t!era,ies? an u,dated re,ort b$ t!e American #ociet$ o Anest!esiologists %as) Force on Perio,erati+e Blood %rans usion and Ad@u+ant %!era,ies/ Anest!esiolog$ 2;;5K ! 8? 11=.2;=/ Decreto del Ministro della #alute 3 Marzo 2;;5/ 3aratteristic!e e modalitV ,er la donazione di sangue e di emocom,onenti/ Gazzetta > Bciale della Re,ubblica "taliana, n/ =5 del 13 a,rile 2;;5/ 3ouncil o 0uro,e/ Guide to the Pre"aration, Use and 7uality (ssurance of +lood Com"onents3 #ecommendation 8o # 90.: 1. on the Pre"aration, Use and 7uality (ssurance of +lood Com"onents3 14t! ed/ #trasbourg? 3ouncil o 0uro,e PressK 2;;=/ #ocietV "taliana di Medicina %ras usionale e "mmunoematologia &#"M%"'/ Standard di Medicina Trasfusionale/ 1a 0d/ Milano? 0dizioni #"M%"K 2;;</ #ocietV "taliana di Medicina %ras usionale e "mmunoematologia/ #accomanda)ioni SIMTI sul corretto utili))o degli emocom"onenti e dei "lasmaderivati/ 1a 0d/ Milano? 0dizioni #"M%"K 2;;=/ Liumbruno G, Bennardello F, Lattanzio A, et al/ Recommendations or t!e trans usion o red blood cells/ Blood %rans us 2;;1K ;? 41.54/ Liumbruno G, Bennardello F, Lattanzio A, et al/ Recommendations or t!e trans usion o ,lasma and ,latelets/ Blood %rans us 2;;1K <? 132.5;/ Practice Guidelines or blood com,onent t!era,$? a re,ort b$ t!e American #ociet$ o Anest!esiologists %as) Force on Blood 3om,onent %!era,$/ Anest!esiolog$ 1115K =6? <32.4< 6ebert P3, 6u LZ, Biro GP/ Re+ie7 o ,!$siologic mec!anisms in res,onse to anemia/ 3an Med Assoc Y 111<K !89? #2<.4;/ 6ebert P3, *an der Linden P, Biro GP, 6u LZ/ P!$siologic as,ects o anemia/ 3rit 3are 3lin 2;;4K 2 ? 1=<.212/ 6ameed #M, Aird (3/ EH$gen deli+er$/ 3rit 3are Med 2;;3K 3!? #55=.5</ 0llis 3G, Yagger Y, #!ar,e M/ %!e microcirculation as a unctional s$stem/ 3rit 3are 2;;5K 1? #3.=/ (allis YP/ Litric oHide and blood? a re+ie7/ %rans us Med 2;;5K !8? 1.11/ 3arson YL, 6ill #, 3arless P, et al/ %rans usion triggers? a s$stematic re+ie7 o t!e literature/ %rans us Med Re+ 2;;2K !9? 1=<.11/ #iegemund M, +an Bommel Y, "nce 3/ Assessment o regional tissue oH$genation/ "ntensi+e 3are Med 1111K 28? 1;44.5;/ 6uang [3/ Monitoring oH$gen deli+er$ in t!e




55' 55'

5<' 5=' 51'

<;' <1' <2' <3' <4' <5' <5' <<'


criticall$ ill/ 3!est 2;;5K !2=? 554#.5;/


#e!gal LR, Selala RP, %a)agi ", et al/ 0+aluation o oH$gen eHtraction ratio as ,!$siologic trans usion trigger in coronar$ arter$ b$,ass gra t surger$ ,atients/ %rans usion 2;;1K 6!? 511.5/ #,a!n DR, Dettori L, Qocian R, 3!assot PG/ %rans usion in t!e cardiac ,atient/ 3rit 3are 3lin 2;;4K 2 ? 251.<1/ (elte M, 6able E/ Die indication zur ,erio,erati+en trasn usion +on er$t!roz$te/ Anaest! "ntensi+med 2;;5K 3? <3.=3/ Mad@d,our 3, Marcucci 3, %issot YD, #,a!n DR/ Perio,erati+e blood trans usion/ *alue, ris)s, and guidelines/ Anaest!esist 2;;5K 86? 5<.=;/ 6ill #R, 3arless PA, 6enr$ DA, et al/ %rans usion t!res!olds and ot!er strategies or guiding allogeneic red blood cell trans usion/ 3oc!rane Database #$st Re+ 2;;2K 2? 3D;;2;42/ German Medical Association/ Cross&Sectional Guidelines for Thera"y ;ith +lood Com"onents and Plasma <erivatives/ 4t! ed/ 2;;1/ A+ailable at? !tt,?99777/bundesaerzte)ammer/de9do7nloads9 Leit3rossBlood3om,onents4ed/,d / Last accessed on? ;392592;1;/ Petz LD, #7is!er #L, Qleinman #, et al/ Clinical Practice of Transfusion Medicine/ 3rd ed/ Le7 [or), L[? 3!urc!ill Li+ingstoneK 1115/ Mur,!$ MF, (allington %B, Qelse$ P, et alK Britis! 3ommittee or #tandards in 6aematolog$, Blood %rans usion %as) Force/ Guidelines or t!e clinical use o red cell trans usions/ Br Y 6aematol 2;;1K !!3? 24.31/ 3linical ,ractice guidelines on t!e use o blood com,onents &red blood cells, ,latelets, res! rozen ,lasma, cr$o,reci,itate'/ 0ndorsed #e,tember 2;;1/ Lational 6ealt! and Medical Researc! 3ouncil, Australasian #ociet$ o Blood %rans usion "nc/ A+ailable at? !tt,?99777/n!mrc/go+/au9,ublications9 s$no,ses9W iles9c,<=/,d / Last accessed on? ;392592;1;/ Miller [, Bac!o7s)i G, Ben@amin R, et al/ Practice Guidelines for +lood Transfusion3 ( Com"ilation from #ecent Peer&#evie;ed 2iterature / 2nd ed/ American Lational Red 3rossK 2;;</ A+ailable at? !tt,?99777/redcross/org9777. iles9Documents9(or)ing(it!t!eRed3ross9 ,racticeguidelines orbloodtrans/,d / Last accessed on? ;392592;1;/ Agence ran_aise de s`curit` sanitaire des ,roduits de sant`/ %rans usion de globules rouges !omologues? ,roduits, indications, alternati+es/ M`t!ode g`n`rale et recommendations/ %rans us 3lin Biol 2;;2K #? 333.55/ Mc3lelland DBL/ !andboo6 of Transfusion Medicine/ 4t! ed/ London, >Q? %#EK 2;;</ #cottis! "ntercollegiate Guidelines Let7or)/ Perio,erati+e blood trans usion or electi+e surger$K Ectober 2;;1/ A+ailable at? !tt,?99777/sign/ac/u)9 ,d 9sign54/,d / Last accessed on? ;392592;1;/ McFarland YG/ Perio,erati+e blood trans usions? indications and o,tions/ 3!est 1111K !!8? #113.21/

<1' =;' =1' =2'


=4' =5'




=1' 1;'


2iumbruno GM et al3


6ebert P3, (ells G, Martin 3, et al/ *ariation in red cell trans usion ,ractice in t!e intensi+e care unit? a multicentre co!ort stud$/ 3rit 3are 1111K 3? 5<.53/

1;=' Li+io M, Gotti 0, Marc!esi D, et al/ >raemic bleeding? 13'

role o anemia and beneBcial e ect o red cell trans usions/ Lancet 11=2K 2? 1;13.5/ Rado+ Riggs #A, et al/ 1;1' Brace$ ance+i #mall M, Lo7e GD, A(, c R, 3ameron 0, Forbes 3D/ , sion t!res!old n G L at sa e in o Y, o ie criticall$ ill n R 7 nt ,atients 7it! # ee er o cardio+ascular %. + in ut disease\ 3rit se es g c 3are Med g B t! o 2;;1K 2#? 22<. m 3 e m 34/ e , ! e/ nt R e 15' (u (3, % el o m Rat!ore ##, ra e g o (ang [, et al/ ns + er gl Blood u at s o trans usion in si io P bi elderl$ o n 3 n ,atients 7it! n a A t! acute 1 c , re m$ocardial 1 ut et s in arction/ L 1 e al ! 0ngl Y Med 1K c / ol 2;;1K 368? 3 or "n d 123;.5/ #? o cr o 1 15' Rao #*, Yollis n ea r ; ar se YG, tr < $ d 6arrington a ;. s m RA, et al/ n </ $ or Relations!i, s n ta o blood u 14' 6 dr lit trans usion si e o $, and clinical o b m , outcomes in n er es os ,atients 7it! in t / to acute c P A , coronar$ or 3 m er s$ndromes/ o , 6 at YAMA 2;;4K n [ e i+ 2#2? 1555.52/ ar et ar e $ is t m ar P3, ir 1<' 6ebert Y or te Fergusson 0, 2 bi r$ DA/ Red M ; di b blood cell ar ; t$ $ trans usion in ti =K , , criticall$ ill n ! a as ,atients/ 3 8 n s YAMA 2;;2K , 8? d ,r 2== ? 1525.5/ et 3 c o al 1=' Rao #*, Qaul 5 os ce / PR, Liao L, et 1. t d "s al/ Association < a ur a bet7een 4/ te es lo bleeding, r ? 11' M 7 blood re e ur tr trans usion, d e a , and costs bl ct ! ns among o o u $ ,atients 7it! o n

d c el l tr a n s u si o n in , at ie nt s ! a +i n g c ar di a c s ur g er $/ 3 ir c ul at io n 2 ; ; <K ! ! 9? 2 5 4 4. 5 2/

1;;' R
a o # *, 3 !i s 7 el l Q , # u n Y

L, ndromes/ Am1;5' L et Y 3ardiol e al 2;;=K ! !? +i / 25.1/ M "n , 1;1' Britis! te % 3ommittee or rn o #tandards in at ! 6aematolog$/ io 3 Guidelines or n 6 t!e use o al , ,latelet + % trans usions/ ar ! Br Y 6aematol ia a 2;;3K !22? ti c 1;.23/ o !i n 1;2' #c!i er A3, l in Anderson Q3, Y, t! Bennet 3L, et ( e al/ Platelet at u trans usion or s se ,atients 7it! o o cancer? n bl clinical 6 o ,ractice G o guidelines o / d t!e American G tr #ociet$ o ui a 3linical d n Encolog$/ Y el s 3lin Encol in u 2;;1K !#? es si 1511.3=/ o o r 1;3' Bosl$ A, n t! Mu$lle L, in e Loens L, et al/ , di Guidelines or at a t!e ie g trans usion o nt n ,latelets/ Acta s o 3lin Belg 7 si 2;;<K 92? 35. it s 4</ ! a n n A, o 1;4' %osetto d n Balduini 3L, m # 3attaneo M, a %. et al/ n se Management a g o bleeding g m and o e e in+asi+e m nt ,rocedures in e el ,atients 7it! nt e ,latelet o + disorders di at and9or ss io t!romboc$to, e n enia? m ac Guidelines o in ut t!e "talian at e #ociet$ or e c 6aemostasis d or and in o %!rombosis tr n &#"#0%'/ a ar %!romb Res + $ 2;;1, !26? as s e13.=/ c $ ul

ar c o a g ul at io n/ B rit is ! 3 o m m itt ee o r #t a n d ar ds in 6 ae m at ol o g $/ B r Y 6 ae m at ol 2 ; ; 1K ! 6 8? 2 4. 3 3/

1;5' #
ea rl e 0, P a + or d A , A lB re

+i c S/ R ec o m bi n a nt a ct or * "" a a n d ot ! er ,r o. ! ae m o st at ic t! er a ,i es in ,r i m ar $ , o st , ar tu m ! ae m or r! a g e/ B es t P ra ct R es 3 li n E b

st et G $ n ae c ol 2 ; ; =K 2 2? 1 ; < 5. = =/

et7een !aematocrit, bleeding time and ,latelet ad!esi+eness/ Br Y 6aematol 1151K ;? 42. 5;/

3 o nt ri b ut io n o t! e ! a e m at o cr it to t! e bl e e di n g ti m e/ 6 a e m o st a si s 1 1 = 3K ! 3? 3 < 1 . = 4/

1;<' 6
el le m A Y, B or c ! gr e +i n ) 3 F, A m es # B / % ! e ro le o re d ce ll s in ! ae m os ta si s? t! e re la ti o n b

11;' F
er n a n d e z F, G o u d a bl e 3 , #

ie P, et al / L o 7 ! a e m at o cr it a n d ,r ol o n g e d bl e e di n g ti m e in ur a e m ic , at ie nt s? e e ct o re d c el l tr a n s u si o n s/ B r Y 6 a e m

at ol 1 1 = 5K 8 #? 1 3 1 . 4 =/

111' 0
s c ol ar G , G ar ri d o M , M a z z ar a R , et al / 0 H , er i m e nt al b a si s o r t! e u s e o re d c el l tr a n

s , La7rence 3/ o u Bleeding si time/ A guide bl o to its e n diagnostic e in and clinical di t! utilit$/ Arc! n e Pat!ol Lab g m Med 11=1K in a !!3? 1211.24/ t! n r 113' 6o 36/ %!e a o !emostatic g m e ect o e b ade-uate red m o cell e c trans usion in nt $t ,atients 7it! o o anemia and , t!romboc$to, a e enia/ n ni %rans usion e c 1115K 39? m , 21;/ ic at . 114' 3ro7le$ YP, ie t! nt Metzger YB, r s *aleri 3R/ o 7 %!e +olume m it o blood s!ed b ! during t!e o a bleeding time c c correlates $t ut 7it! t!e o e ,eri,!eral , m +enous e $ !ematocrit/ ni el Am Y 3lin c oi Pat!ol 111<K , d ! =? 5<1.=4/ at le 115' *aleri 3R, ie u 3assid$ G, nt ) Pi+ace) L0, s/ e et al/ Anemia. % m induced ra ia increase in t!e n / bleeding time? s 6 im,lications u a or treatment si e o nonsurgical o m blood loss/ n at %rans usion 1 ol 2;;1K 6!? 1 o 1<<.=3/ = gi M, =K 115' 0ugster c 2 a Rein!art (6/ =? 2 %!e in luence 4 ; o t!e ; ; !ematocrit on 5 5K ,rimar$ . 6 !aemostasis 1 !? in +itro/ 1/ 1 %!romb 5 6aemost 112' B 3 2;;5K #6? u ; 1213.=/ r . n 11<' (ebert Q0, </ s 3oo) RY, 0 #igouin 3#, 11=' ( R e et al/ %!e ris)

b er t Q 0, 3 o o ) R Y, 3 o u b a n #, et al / A m ul ti ce nt er ,i lo t. ra n d o m iz e d c o nt ro ll e d tri al o t! e e as ib ili t$ o a n a u g m e nt e d re d bl o

o d ce ll tr a ns u si o n st ra te g $ o r , at ie nt s tr ea te d 7 it ! in d u ct io n c ! e m ot ! er a , $ o r ac ut e le u ) e m ia or st e m ce ll tr a ns ,l a nt at io

n/ dards in %r 6aematolog$/ an Guidelines or s t!e use o us res!. rozen io ,lasma, n cr$o,reci,itat 2 e and ; cr$osu,ernata ; nt/ Br Y =K 6aematol 6 2;;4K !29? =? 11.2=/ = 12;' Agence 1. Fran_aise de 1 #`curit` 1/ #anitaire des 111' E Produits de #ant`/ I# %rans usion de ! ,lasma rais a congel`? u ,roduits, g indications, ! m`t!ode n g`n`ral et es recommandati s ons/ %rans $ 3lin Biol D 2;;2K #? 322. F, 32/ A tt 121' 6ellstern P, er Muntean (, b #c!ramm (, u et al/ Practical r guidelines or $ t!e clinical 3 use o ,lasma/ , %!romb Res B 2;;2K #8? 53. ol </ to n 122' Simmerman M YL/ >se o a blood g ,roducts in g se,sis? an s e+idence. P, based re+ie7/ et 3rit 3are Med al 2;;4K 32? K #542.</ B 123' Le+i M/ ri 3urrent ti understanding s o ! disseminated 3 intra+ascular o coagulation/ m Br Y 6aematol m 2;;4K !26? it 55<.<5/ te e 124' (illiamson LM/ 3orrecting o !aemostasis/ r *oH #ang # ta n


+lood Transf us %/11$0 1*%/& *. DE" 1;/245 ;92;11 /;;<5. 1;

The "ost&o"erative "eriod 2;;4K =;? #51.</ +lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;

125' Gouezec 6, Yego P, BetremieuH P, et al/ "ndications

or use o labile blood ,roducts and t!e ,!$siolog$ o blood trans usion in medicine/ %!e Frenc! Agenc$ or t!e 6ealt! #a et$ o 6ealt! Products/ %rans us 3lin Biol 2;;5K !2? 151.<5/ t!e e+idence or t!e clinical use o FFP and ,lasma ractions/ Best Pract Res 3lin 6aematol 2;;5K !#? 5<.=2/

125' #tan7ort! #Y, Bruns)ill #Y, 6$de 3Y, et al/ A,,raisal o

3ommittee or #tandards in 6ematolog$/ Guidelines on t!e management o massi+e blood loss/ Br Y 6aematol 2;;5K !38? 534.41/ 12=' Dzi ) (6/ %!e L6LB" 3linical %rials Let7or) in trans usion medicine and !emostasis? an o+er+ie7/ Y 3lin A,!er 2;;5K 21? 5<.1/

12<' Britis!

121' 6olland

LL, Broo)s YP/ %o7ard rational res! rozen ,lasma trans usion/ Am Y 3lin Pat!ol 2;;5K !29? 133.1/ #Y, Bruns)ill #Y, 6$de 3Y, et al/ "s res! rozen ,lasma clinicall$ e ecti+e\ A s$stematic re+ie7 o randomised controlled trials/ Br Y 6aematol 2;;4K !29? 131.52/ E, Dzi) (6, %o$ P/ Fres! rozen ,lasma and ,latelet trans usion or non bleeding ,atients in t!e intensi+e care unit? beneBt or !arm\ 3rit 3are Med 2;;5K 36? #1<;.3/ 6azards o %rans usion Annual Re,ort 2;;=/ %!e #erious 6azards o %rans usion #teering Grou,/ A+ailable at? !tt,?99777/s!otu)/org9#6E%:2; Re,ort :2;2;;=/,d / Last accessed on? ;392592;1;/ rancaise de s`curit` sanitaire des ,roduicts de sant`/ A+ailable at? !tt,?99777/a ssa,s/ r9content9se arc!\ #earc!%eHtU!emo+igilance/ Last accessed on? ;392592;1;/ 3, #,a!n DR/ Allogeneic red blood cell trans usions? e Bcac$, ris)s, alternati+es and indications/ Br Y Anaest! 2;;5K #8? 33.42/ trans usion\ 3rit 3are 3lin 2;;1K 28? 251.<</

13;' #tan7ort!

131' Ga@ic

132' #erious

133' Ra,,ort Annuel 6`mo+igilance 2;;</ Agence

134' Mad@d,our

135' #!ander A, Goodnoug! L%/ (!$ an alternati+e to blood 135' Bierbaum

B0, 3allag!an YY, Galante YE, et al/ An anal$sis o blood management in ,atients !a+ing a total !i, or )nee art!ro,last$/ Y Bone Yoint #urg Am 1111K =!? 2.1;/ A, et al/ Ris) o bacterial in ection associated 7it! allogeneic blood trans usion among ,atients undergoing !i, racture re,air/ %rans usion 1111K 3#? 514.<;;/ or minimising ,erio,erati+e allogeneic blood trans usion/ 3oc!rane Database #$st Re+ 2;;5K 6? 3D;;1===/

13<' 3arson YL, Altman DG, Du

13=' 3arless PA, 6enr$ DA, MoHe$ AY, et al/ 3ell sal+age

131' #inardi D, Marino A, 3!illemi #, et al/ 3om,osition o

t!e blood sam,led rom surgical drainage a ter @oint art!ro,last$? -ualit$ o return/ %rans usion 2;;5K 68? 2;2.</

14;' Da+is

RY, Agne7 DQ, #!earl$ 3R, et al/ 0r$t!roc$te +iabilit$ in ,osto,erati+e autotrans usion/ Y Pediatr Ert!o, 1113K !3? <=1.3/


141' Ra$

YM, Fl$n Y3, Bierman A6/ 0r$t!roc$te sur+i+al ollo7ing intrao,erati+e autotrans usion in s,inal surger$? an in +i+o com,arati+e stud$ and 5.$ears u,date/ #,ine 11=5K !!? =<1.=2/ M, Garcia.*alle@o YY, Ruiz MD, et al/ %rans usion o ,ost.o,erati+e s!ed blood? laborator$ c!aracteristics and clinical utilit$/ 0ur #,ine Y 2;;;K !3? #1;<.13/ actor antigen and acti+it$ in serum o ,osto,erati+el$ s!ed blood used or autologous trans usion/ Blood 3oagul Fibrinol$sis 2;;;K !!? 211.23/

142' Mu]oz

143' Qro!n 3D, Rei)eras E, B@onsern #, Brosstad %/ %issue

144' Qro!n

3D, Rei)eras E, B@onsern #, Brosstad %/ Fibrinol$tic acti+it$ and ,osto,erati+e sal+aged untreated blood or autologous trans usion in ma@or ort!o,aedic surger$/ 0ur Y #urg 2;;1K !9;? 15=.<2/ c$to)ines, ,ol$mor,!onuclear elastase and terminal 35b.1 com,lement com,leH b$ in usion o 7ound drainage blood/ Acta Er!o, #cand 1115K 99? 334.=/

145' Arnestad YP, Bengtsson A, Bengtson YP, et al/ Release o

145' Dalen

%, Bengtsson A, Brorsson B, 0ngstrom QG/ "nGammator$ mediators in autotrans usion drain blood a ter )nee art!ro,last$, 7it! and 7it!out leucoc$te reduction/ *oH #ang 2;;3K =8? 31.1/ 3D, Rei)eras E, Molness %0/ 3om,lement acti+ation and increased s$stemic and ,ulmonar$ +ascular resistance indices during in usion o ,osto,erati+el$ drained untreated blood/ Br Y Anaest! 1111K =2? 4<.51/ %, Pincemail Y, Bla art F, et al/ Le+els o inGammator$ mar)ers in t!e blood ,rocessed b$ autotrans usion de+ices during cardiac surger$ associated 7it! cardio,ulmonar$ b$,ass circuit/ Per usion 2;;2K !;? 11<.23/ M, 3obos A, 3am,os A, et al/ Post.o,erati+e un7as!ed s!ed blood trans usion does not modi $ t!e cellular immune res,onse to surger$ or total )nee re,lacement/ Acta Anaest!esiol #cand 2;;5K 8 ? 443.5;/

14<' Qro!n

14=' Amand

141' Mu]oz

15;' 6ansen 0, 6ansen MP/ Reason against t!e retrans usion

o un7as!ed 7ound blood/ %rans usion 2;;4K 66 &12 #u,,l'? 45#.53/

151' Qeating

0M, Meding YB/ Perio,erati+e blood management ,ractices in electi+e ort!o,aedic surger$/ Y Am Acad Ert!o, #urg 2;;2K ! ? 313.4;;/ Glo+er YL, Bendic) PY, et al/ 3ell 7as!ing +ersus immediate rein usion o intrao,erati+el$ s!ed blood during abdominal aortic re,air/ Am Y #urg 1113K !99? 1<.1;2/ R3, 3arlson Q#, Morgan YM, et al/ "n +itro anal$sis o s!ed blood rom ,atients undergoing total )nee re,lacement surger$/ Am Y 3lin Pat!ol 1114K ! !? 355.1/ 7ound drainage blood? 7!at are 7e gi+ing our ,atients\ 3lin Ert!o, 1115K 32 ? 235.45/

152' Long G(,

153' Bla$loc)

154' #out!ern 0P, 6uo M6, Me!ta YR, Qeggi QY/ >n7as!ed 155' Gri
it! LD, Billman GF, Dail$ PE, Lane %A/ A,,arent coagulo,at!$ caused b$ in usion o s!ed mediastinal blood and its ,re+ention b$ 7as!ing o

1<;' Ma!
t!e in usate/ Ann %!orac #urg 11=1K 6;? 4;;.5/

0%, Da+is R, #es!adri P, et al/ %!e role o autologous blood trans usion in @oint re,lacement surger$/ Anaest! "ntensi+e 3are 1115K 23? 4<2.</

155' Rubens

FD, Bood!7ani M, La+alee G, Mesata %/ Perio,erati+e red blood cell sal+age/ 3an Y Anest! 2;;3K 8 ? #31.4;/ ects o ,osto,erati+e in usion o s!ed mediastinal blood/ Ann %!orac #urg 1115K 92? <1<.23/ MYR, Da7)ins #, Pac) L, et al/ Autotrans usion decreases blood usage ollo7ing cardiac surger$? a ,ros,ecti+e randomised trial/ 3ardio+asc #urg 2;;1K #? 1=4.</ autologous red cell sal+age +ersus allogeneic red cell trans usion during abdominal aortic aneur$sm re,air/ Anaest! "ntensi+e 3are 2;;;K 2=? 545.1/

15<' *ertrees RA, 3onti *R, Lic) #D, et al/ Ad+erse e 15=' Dalr$m,le.6a$

151' Gardner A, Gibbs M, 0+ans 3, Bell R/ Relati+e cost o

15;' (al,ot! B6, 0ggens,erger L, (al,ot!.Aslan BL, et al/

Zualitati+e assessment o blood 7as!ing 7it! t!e continuous autologous trans usion s$stem &3A%#'/ "nt Y Arti Ergans 111<K 2 ? 234.1/

151' 6uet 3, #almi LR, Fergusson D, et al/ A meta.anal$sis

o t!e e ecti+eness o cell sal+age to minimize ,erio,erati+e allogeneic blood trans usion in cardiac and ort!o,edic surger$/ Anest! Analg 1111K =#? =51.1/

152' Mu]oz

M, Ariza D, Garceran MY, et al/ BeneBts o ,osto,erati+e s!ed blood rein usion in ,atients undergoing unilateral total )nee re,lacement/ Arc! Ert!o, %rauma #urg 2;;5K !28? 3=5.1/ AF3M, Qnoors L%, +an Es YY, et al/ Retrans usion o Bltered s!ed blood in ,rimar$ total !i, and )nee art!ro,last$? a ,ros,ecti+e randomized clinical trial/ %rans usion 2;;<K 6;? 3<1.=4/ are more li)el$ to beneBt rom ,osto,erati+e s!ed blood sal+age a ter unilateral total )nee re,lacement\ An anal$sis o 5=1 consecuti+e ,rocedures/ *oH #ang 2;;<K #2? 135.41/

153' Moonen

154' Munoz M, Qu!lmorgen B, Ariza D, et al/ (!ic! ,atients

155' Moonen 155' Lorentz 15<' #lagis

AF3M, %!omassen BY(, +an Es YY, et al/ Retrans usion o Bltered s!ed blood in e+er$da$ ort!o,aedic ,ractice/ %rans us Med 2;;=K !=? 355.1/ A, Ess7ald PM, #c!illing M, Yani L/ A com,arison o autologous trans usion ,rocedures in !i, surger$/ Anaest!esist 1111K 6 ? 2;5.13/ #*, Ben@amin YB, *olz RG, Giordano GF/ Posto,erati+e blood sal+age in total !i, and )nee art!ro,last$/ A randomised controlled trial/ Y Bone Yoint #urg Br 1112K ;6? 154.5/ %, Ru,, D, +an Lessen A, 6em,elmann G/ Measures or reducing t!e use o !omologous blood/ 0 ects on blood coagulation during total endo,rost!esis/ Anaest!esist 1112K 6!? 2<.33/ . +an Gemert A(MM / Processed autotrans usion and !omologous red cell re-uirement in electi+e cardiac and ort!o,aedic surger$? a randomised ,ros,ecti+e stud$/ "n? Perio"erative (utotransfusion by Means of a +lood Cell Se"arator / Den 6aag? 3i,.Data Qonin)li@)e Bibliot!ee)K 113/ ,/ 1;5.25/

15=' Menges

151' Qoo,man

2iumbruno GM et al3

controlled stud$ a ter )nee re,lacement/ Y Bone Yoint #urg Br 111<K ;#? 53;.2/

1<1' Rollo *Y, 6ozac) (Y, Rot!man R6, et al/ Pros,ecti+e

randomised e+aluation o blood sal+age tec!ni-ues or ,rimar$ total !i, art!ro,last$/ Y Art!ro,last$ 1115K ! ? 532.1/

1=<' Adalbert! G, B$strom #, Qolstad Q, et al/ Posto,erati+e

+lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1;

1<2' 0)bac)

G, #c!ott >, AHelsson Q, 3arberg M/ Perio,erati+e autotrans usion and unctional coagulation anal$sis in total !i, re,lacement/ Acta Anaest!esiol #cand 1115K 3#? 31;.5/ A, (are!am Q, Le7ington D, et al/ 3ell sal+age autotrans usion in total )nee re,lacement surger$/ %rans us Med 111<K ;? 2<<.=;/ D, (are!am Q, 3o!en D, 6utc!ings 6/ Autologous blood trans usion in total )nee re,lacement surger$/ Br Y Anaest! 2;;1K =9? 551.<3/ 3R, #,ratt QF, Blondin M, et al/ Perio,erati+e autotrans usion in total !i, and )nee art!ro,last$/ Y Art!ro,last$ 2;;5K 2!? 23.35/
R#, 3urrie "3, Le7man Y6/ Posto,erati+e collection and rein usion o autologous blood in total )nee art!ro,last$/ Ann R 3oll #urg 0ngl 1111K ;3? 3=1.4/

1<3' #!enoli)ar 1<4' %!omas 1<5' 3lar)

1<5' Ma@)o7s)i 1<<' Gannon

DM, Lombardi A* Yr, Mallor$ %6, et al/ An e+aluation o t!e e Bcac$ o ,osto,erati+e blood sal+age a ter total @oint art!ro,last$/ A ,ros,ecti+e randomized trial/ Y Art!ro,last$ 1111K 9? 1;1.14/ trial on t!e e Bcac$ o an autologous blood drainage and trans usion de+ice in ,atients undergoing electi+e )nee art!ro,last$/ %rans usion 1112K 32? <42.5/

1<=' 6eddle LM, BroH (%, Qlama LL, et al/ A randomized

1<1' Mauer!an

DR, Lussman D, Mo)ris YG, Bea+er (B/ 0 ect o ,osto,erati+e rein usion s$stems on !emoglobin le+els in ,rimar$ total !i, and total )nee art!ro,lasties/ A ,ros,ecti+e randomized stud$/ Y Art!ro,last$ 1113K =? 523.</ P ei er BA, Qurtz #R, et al/ 0+aluation o autologous s!ed blood or autotrans usion a ter ort!o,aedic surger$/ 3lin Ert!o, 1114K 2##? 53.1/ B, Aroc) M, Guerrero M, et al/ 6aematological e ects o ,osto,erati+e autotrans usion in s,inal surger$/ Acta Anaest!esiol #cand 1114K 3=? 335.41/ *, %allet F, et al/ 3om,arison o Ert!.0+ac and #olcotrans Plus de+ices or t!e autotrans usion o blood drained a ter total )nee @oint art!ro,last$/ Ann Fr Anest! Reanim 1114K !3? 31=.25/ %!e e ect o ,osto,erati+e 7ound drainage rein usion in reducing t!e need or blood trans usions in electi+e total @oint art!ro,last$? a ,ros,ecti+e, randomized stud$/ Ert!o,edics 1114K !;? 133.</

1=;' 6eal$ (L, 1=1' Riou

1=2' Rosenc!er L, *assilie

1=3' #im,son MB, Mur,!$ QP, 3!ambers 6G, Buc)nell AL/

1=4' A$ers D3, Murra$ DG, Duerr DM/ Blood sal+age a ter
total !i, art!ro,last$/ Y Bone Yoint #urg Am 1115K ;;? 134<.51/

1=5' Rollo *Y, 6ozac) (Y, Rot!man R6, et al/ Pros,ecti+e

randomised e+aluation o blood sal+age tec!ni-ues or ,rimar$ total !i, art!ro,last$/ Y Art!ro,last$ 1115K ! ? 532.1/

1=5' Le7man

Y6, Bo7ers M, Mur,!$ Y/ %!e clinical ad+antages o autologous trans usion? a randomised,

The "ost&o"erative "eriod +lood Transfus %/11$01*%/&*. DE" 1;/245;92;11/;;<5.1; drainage o )nee art!ro,last$ is not necessar$? a randomised stud$ o 1; ,atients/ Acta Ert!o, #cand 111=K 9#? 4<5.=/

1==' %!urer

RL, L$tle B(, 3osgro+e DM, Loo, FD/ Autotrans usion ollo7ing cardiac o,erations? a randomized, ,ros,ecti+e stud$/ Ann %!orac #urg 11<1K 2;? 5;;.</ blood utilization during m$ocardial re+ascularization/ Y %!orac 3ardio+asc #urg 11=1K #;? 213.1/

1=1' Dietric! (, Baran)a$ A, Dilt!e$ G, et al/ Reduction o 11;' Page 111' 0ng
R, Russell GL, FoH MA, et al/ 6ard.s!ell cardiotom$ reser+oir or rein usion o s!ed mediastinal blood/ Ann %!orac #urg 11=1K 6=? 514.</ Y, Qa$ P6, Murda$ AY, et al/ Posto,erati+e autologous trans usion in cardiac surger$? a ,ros,ecti+e, randomised stud$/ 0ur Y 3ardiot!orac #urg 111;K 6? 515. 5;;/ R/ An e+aluation o clinical as,ects o ,ost. o,erati+e autotrans usion, eit!er alone or in con@unction 7it! ,reo,erati+e as,irin, in cardiac surger$/ Br Y 3lin Pract 1111K 68? 1;5.1=/ *, Radegran Q/ Autotrans usion o mediastinal blood in cardiac surger$/ #cand Y %!orac 3ardio+asc #urg 11=1K 23? 4<.1/ YP, Bred`e Y, #,ee)enbrin) RG, et al/ Autotrans usion o s!ed blood contributes additionall$ to blood sa+ing in ,atients recei+ing a,rotinin &2 million Q">'/ 0ur Y 3ardiot!orac #urg 1113K ;? 4<4.</

112' #!ir+ani

113' Le,ore

114' #c!anberger

115' Laub G(, D!aran M, Riebman YB, et al/ %!e im,act o

intrao,erati+e autotrans usion on cardiac surger$/ A ,ros,ecti+e randomized double.blind stud$/ 3!est 1113K ! 6? 5=5.1/

115' (ard

6B, #mit! RR, Landis QP, et al/ Pros,ecti+e, randomized trial o autotrans usion a ter routine cardiac o,erations/ Ann %!orac #urg 1113K 89? 13<.41/ %3, Dearani YA, Ragno G, et al/ #a et$ and t!era,eutic e ecti+eness o rein used s!ed blood a ter o,en !eart surger$/ Ann %!orac #urg 1114K 8;? 515.22/ L, Qardara M, Qeste+en PY, Ya$a)ris!nan AG/ Autotrans usion a ter coronar$ arter$ b$,ass surger$? is t!ere an$ bene it\ Y 3ard #urg 1114K #? 314. 21/ o t!e blood drained rom mediastinum in t!e course o m$ocardial re+ascularization/ Acta Biomed Ateneo Parmense 1115K 99? 115.2;1/

11<' AH ord

11=' Bouboulis

111' Fragnito 3, Beg!i 3, 3a+ozza 3, et al/ Autotrans usion

2;;' #c!midt

6, Mortensen P0, Folsgaard #L, Yensen 0A/ Autotrans usion a ter coronar$ arter$ b$,ass gra ting !al+es t!e number o ,atients needing blood trans usion/ Ann %!orac #urg 1115K 9!? 11<<.=1/ MY, Qallis P, 3o7an D, et al/ A ,ros,ecti+e randomised controlled trial o ,osto,erati+e autotrans usion 7it! and 7it!out a !e,arin.bonded circuit/ 0ur Y 3ardiot!orac #urg 1115K ! ? 3=.4</ Q, Riao M, Deng #/ Autotrans usion o s!ed mediastinal blood a ter o,en !eart o,eration/ S!ong!ua (ai Qe Sa S!i 1115K 36? 41<.1/ MY, Pac) L, Dea)in 3D, et al/ Autotrans usion o 7as!ed s!ed mediastinal Guid decreases re-uirement or autologous blood trans usion ollo7ing cardiac surger$? a ,ros,ecti+e randomized trial/ 0ur Y 3ardiot!orac #urg 1111K !8? =3;.4/ mediastinal blood a ter !eart surger$/ Y %!orac 3ardio+asc #urg 2;;;K !2 ? 411.5;4/

2;1' >ns7ort!.(!ite

2;2' S!ao

2;3' Dalr$m,le.6a$

2;4' Martin Y, Robitaille D, Perrault LP, et al/ Rein usion o 2;5' Laumen)o
#0, Po)ro+s)ii MG, Bela+in A#, Qim #F/ e ecti+eness o ,reo,erati+e reser+ation o autoblood or surgical treatment o isc!aemic !eart disease/ *estn Q!ir "m " " Gre) 2;;3K !92? 51.54/ Q, Ru Y, 6u #, (u Z, et al/ Autotrans usion o s!ed mediastinal blood a ter o,en !eart surger$/ 3!in Med Y &0ngl' 2;;3K !!9? 11<1.=2/ ,rocessing/ %rans us Med Re+ 2;;2K !9? 45.5;/

2;5' S!ao

2;<' #o7emino.3o)er #E/ Red blood cell !emol$sis during 2;=' #,ector 2;1' Aaron
Y", 3rosb$ (6/ 3oagulation studies during eH,erimental !emoglobinemia in !umans/ Y A,,l P!$siol 11<5K 3=? 115.=/ RQ, Beazle$ RM, Riggle G3/ 6ematologic integrit$ a ter intrao,erati+e allotrans usion/ 3om,arison 7it! ban) blood/ Arc! #urg 11<4K ! =? =31.</ R, 6eidenreic! D, (eisbac! *, et al/ "n +itro -ualit$ control o red blood cell concentrates outdated in clinical ,ractice/ %rans us 3lin Biol 2;;3K ! ? 2<5.=3/

21;' Simmermann

%orrespondence? Giancarlo Maria Liumbruno *iale "talia, 11 5<125 Li+orno, "tal$ e.mail? giancarlobliumbruno/it

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