Patient Blood Management (Teil 2) – Praktisches Vorgehen: die 3 Säulen

Zusammenfassung

Patient Blood Management (PBM) ist ein multidisziplinäres, evidenzbasiertes Behandlungskonzept mit dem Ziel, das endogene Blutvolumen von Patienten weitgehend zu bewahren und – wo angezeigt – zu verbessern. PBM basiert auf 3 sich ergänzenden Säulen: erstens der Optimierung des (präoperativen) Erythrozytenvolumens, zweitens der Minimierung des diagnostischen, interventionellen und operativen Blutverlusts und drittens der Ausnützung und Unterstützung der individuellen, physiologischen Anämietoleranz bei strenger Indikationsstellung zur Bluttransfusion. Die Anwendung von PBM reduziert demnach systematisch den Einfluss von 3 Faktoren, die den Krankheitsverlauf negativ beeinflussen können: Anämie, Blutverlust und Transfusion. PBM ist besonders bei Patienten mit erhöhtem Anämie- und Transfusionsrisiko angezeigt und sorgt für individualisierte Behandlungsstrategien. Dadurch werden nicht nur diese Risiken reduziert, sondern auch Versorgungsengpässe verringert und stark steigende Kosten in Verbindung mit Transfusionen eingespart.

Abstract

Patient blood management (PBM) is a patient-specific multidisciplinary, multimodal, evidence-based concept to appropriately conserve and manage a patient's own blood as a vital resource. PBM is based on 3 pillars: the first is the optimization of the patient's endogenous red cell mass, the second is the minimization of bleeding and blood loss and the third involves harnessing and optimizing the patient-specific physiological tolerance of anemia, including adopting more restrictive transfusion thresholds. PBM primarily identifies patients at risk of transfusion and provides a management plan aimed at reducing or eliminating the need for allogeneic transfusion, thus reducing the inherent risks, inventory pressures and the escalating costs associated with transfusion. PBM is applicable to surgical and medical patients. The application of PBM systematically reduces the impact of 3 major contributors to negative outcome: anemia, blood loss and transfusion.

Kernaussagen

• Vor elektiven Eingriffen mit signifikantem Blutverlust werden über 90 % aller präoperativen Anämien nicht behandelt. Die Folge ist eine 3–4-fach höhere Transfusionrate.

• Patienten sollten mindestens 3–4 Wochen vor der Operation der Anästhesieambulanz vorgestellt werden, um Risikofaktoren wie eine päoperative Anämie zu identifizieren und entsprechend zu behandeln.

• Zur Optimierung des Erythrozytenvolumens (1. Säule) können präoperativ der Eisenstatus mit Eisen i. v. optimiert und der Hämoglobinspiegel mit Erythropoetin (POE) angehoben werden (unter Berücksichtigung aller Kontraindikationen).

• Der Blutverlust kann durch folgende Methoden reduziert werden: geeignete Anästhesieverfahren und chirurgische Techniken, Retransfusion von Wundblut sowie optimales Gerinnungsmanagement.

• Wenn keine akute Blutung besteht, entbehrt die immer wieder geübte Transfusion von 2 Erythrozytenkonzentraten jeder Grundlage. Vielmehr sollte nach jeder einzelnen Transfusion die Indikation zur Bluttransfusion erneut überprüft werden.

Schlüsselwörter:

Anämie - Transfusion - Blutverlust - präoperativ - Erythropoetin - Eisen - Patient Blood Management

Key words:

anemia - transfusion - blood loss - erythropoetin - iron - patient blood management

• Literatur

• 1 Gombotz H, Hofmann A, Rehak P, Kurz J. Patient Blood Management (Teil 1) – Individuelles Behandlungskonzept zur Reduktion und Vermeidung von Anämie, Blutverlust und -transfusionen. Anästhesiol, Intensivmed, Notfallmed, Schmerzther 2011; 46: 396-401
• 2 Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery the Austrian benchmark study. Transfusion 2007; 47: 1468-1480
• 3 Bennett-Guerrero E, Zhao Y, O'Brien SM et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010; 304: 1568-1575
• 4 Moskowitz DM, McCullough JN, Shander A et al. The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective?. Ann Thorac Surg 2010;
• 5 Shander A, Hofmann A, Ozawa S et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010; 50: 753-765
• 6 Ferraris VA, Brown JR, Despotis GJ et al. 2011 update to the society of thoracic surgeons and the society of cardiovascular anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91: 944-982
• 7 Beris P, Munoz M, Garcia-Erce JA et al. Perioperative anaemia management: consensus statement on the role of intravenous iron. Br J Anaesth 2008; 100-100
• 8 Wish JB. Assessing iron status: beyond serum ferritin and transferrin saturation. Clin J Am Soc Nephrol 2006; (Suppl. 01)
• 9 Theusinger OM, Leyvraz PF, Schanz U et al. Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology 2007; 107: 923-927
• 10 Zauber NP, Zauber AG, Gordon FJ et al. Iron supplementation after femoral head replacement for patients with normal iron stores. JAMA 1992; 267: 525-527
• 11 Ganzoni AM. Intravenous iron-dextran: therapeutic and experimental possibilities. Schweiz Med Wochenschr 1970; 100: 301-303
• 12 Goodnough LT, Verbrugge D, Marcus RE, Goldberg V. The effect of patient size and dose of recombinant human erythropoietin therapy on red blood cell volume expansion in autologous blood donors for elective orthopedic operation. J Am Coll Surg 1994; 179: 171-176
• 13 Mercuriali F, Intaglietta M. Proposal of an algorithm to help the choice of the best transfusion strategy. Curr Med Res Opin 1996; 13: 465-478
• 14 Mercuriali F, Inghilleri G, Biffi E et al. Comparison between intravenous and subcutaneous recombinant human erythropoietin (Epoetin alfa) administration in presurgical autologous blood donation in anemic rheumatoid arthritis patients undergoing major orthopedic surgery. Vox Sang 1997; 72: 93-100
• 15 Bokemeyer C, Aapro MS, Courdi A et al. EORTC guidelines for the use of erythro-poietic proteins in anaemic patients with cancer: 2006 update. Eur J Cancer 2007; 43: 258-270
• 16 Auerbach M, Goodnough LT, Picard D, Maniatis A. The role of intravenous iron in anemia management and transfusion avoidance. Transfusion 2008; 48: 988-1000
• 17 Weltert L, D'Alessandro S, Nardella S et al. Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: a randomized blind controlled study. J Thorac Cardiovasc Surg 2009; 139: 621-627
• 18 Na HS, Shin SY, Hwang JY et al. Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty. Transfusion 2011; 51: 118-124
• 19 Goodnough LT, Rudnick S, Price TH et al. Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy. N Engl J Med 1989; 321: 1163-1168
• 20 Kulier AH, Gombotz H, Fuchs G et al. Subcutaneous recombinant human erythropoietin and autologous blood donation before coronary artery bypass surgery. Anesth Analg 1993; 76: 102-106
• 21 Chun TY, Martin S, Lepor H. Preoperative recombinant human erythropoietin injection versus preoperative autologous blood donation in patients undergoing radical retropubic prostatectomy. Urology 1997; 50: 727-732
• 22 Gombotz H, Gries M, Sipurzynski S et al. Preoperative treatment with recombinant human erythropoietin or predeposit of autologous blood in women undergoing primary hip replacement. Acta Anaesthesiol Scand 2000; 44: 737-742
• 23 Qvist N, Boesby S, Wolff B, Hansen CP. Recombinant human erythropoietin and hemoglobin concentration at operation and during the postoperative period: reduced need for blood transfusions in patients undergoing colorectal surgery – prospective double-blind placebo-controlled study. World J Surg 1999; 23: 30-35
• 24 Feagan BG, Wong CJ, Kirkley A et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med 2000; 133: 845-854
• 25 Addeo R, Caraglia M, Frega N et al. Two faces for Janus: recombinant human erythropoiesis-stimulating agents and cancer mortality. Expert Rev Hematol 2009; 2: 513-515
• 26 Brookhart MA, Schneeweiss S, Avorn J et al. Comparative mortality risk of anemia management practices in incident hemodialysis patients. JAMA 2010; 303: 857-864
• 27 Lorentz A, Jendrissek A, Eckardt KU et al. Serial immunoreactive erythropoietin levels in autologous blood donors. Transfusion 1991; 31: 650-654
• 28 Lee GC, Cushner FD. The effects of preoperative autologous donations on perioperative blood levels. J Knee Surg 2007; 20: 205-209
• 29 Tinmouth A, Fergusson D, Yee IC, Hebert PC. Clinical consequences of red cell storage in the critically ill. Transfusion 2006; 46: 2014-2027
• 30 Gauvin F, Spinella PC, Lacroix J et al. Association between length of storage of transfused red blood cells and multiple organ dysfunction syndrome in pediatric intensive care patients. Transfusion 2010; 50: 1902-1913
• 31 van de Watering L. Red cell storage and prognosis. Vox Sang 2011; 100: 36-45
• 32 Sowade O, Warnke H, Scigalla P et al. Avoidance of allogeneic blood transfusions by treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing open-heart surgery. Blood 1997; 89: 411-418
• 33 Forgie MA et al. for the International Study of Perioperative Transfusion Investigators.. Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion: results of a meta-analysis. Arch Intern Med 1998; 158: 610-616
• 34 de Benoist B, McLean E, Egli I, Cogswell M (ed.) Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. WHO Library Cataloguing-in-Publication Data 2008;
• 35 Guralnik JM, Eisenstaedt RS, Ferrucci L et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood 2004; 104: 2263-2268
• 36 Ania BJ, Suman VJ, Fairbanks VF, Melton LJ. Prevalence of anemia in medical practice: community versus referral patients. Mayo Clin Proc 1994; 69: 730-735
• 37 Endres HG, Wedding U, Pittrow D et al. Prevalence of anemia in elderly patients in primary care: impact on 5-year mortality risk and differences between men and women. Current Medical Research and Opinion 2009; 25: 1143-1158
• 38 Fleisher LA, Beckman JA, Brown KA et al. ACC/AHA 2007 Guidelines on peri-operative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2007; 116
• 39 Goodnough LT, Shander A, Spivak JL et al. Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg 2005; 101: 1858-1861
• 40 Goodnough LT, Maniatis A, Earnshaw P et al. Detection, evaluation, and manage-ment of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011; 106: 13-22
• 41 Shander A, Spence RK, Auerbach M. Can intravenous iron therapy meet the unmet needs created by the new restrictions on erythropoietic stimulating agents?. Transfusion 2010; 50: 719-732
• 42 Bolger AP, Bartlett FR, Penston HS et al. Intravenous iron alone for the treatment of anemia in patients with chronic heart failure. J Am Coll Cardiol 2006; 48: 1225-1227
• 43 Toblli JE, Lombrana A, Duarte P, Di GF. Intravenous iron reduces NT-pro-brain natriuretic peptide in anemic patients with chronic heart failure and renal insufficiency. J Am Coll Cardiol 2007; 50: 1657-1665
• 44 Anker SD, Comin CJ, Filippatos G et al. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 2009; 361: 2436-2448
• 45 Kell D. Iron behaving badly: inappropriate iron chelation as a major contributor to the aetiology of vascular and other progressive inflammatory and degenerative diseases. BMC Medical Genomics 2009; 2
• 46 Weinberg ED. Iron depletion: a defense against intracellular infection and neoplasia. Life Sci 1992; 50: 1289-1297
• 47 Daoud E, Nakhla E, Sharma R. Q: Is iron therapy for anemia harmful in the setting of infection?. Cleveland Clinic Journal of Medicine 2011; 78: 168-170
• 48 Caro JJ, Salas M, Ward A, Goss G. Anemia as an independent prognostic factor for survival in patients with cancer: a systemic, quantitative review. Cancer 2001; 91: 2214-2221
• 49 Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med 2005; 352: 1011-1023
• 50 Henry DH. Parenteral iron therapy in cancer-associated anemia. Hematology 2010; 2010: 351-356
• 51 Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth 2005; 95: 130-139
• 52 Hess JR, Brohi K, Dutton RP et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008; 65: 748-754
• 53 Niles SE, McLaughlin DF, Perkins JG et al. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma 2008; 64: 1459-1463
• 54 Filicori F, Di Saverio S, Casali M et al. Packing for damage control of nontraumatic intra-abdominal massive hemorrhages. World J Surg 2010; 34: 2064-2068
• 55 Zwart JJ, Dijk PD, van Roosmalen J. Peripartum hysterectomy and arterial embo-lization for major obstetric hemorrhage: a 2-year nationwide cohort study in the Netherlands. Am J Obstet Gynecol 2010; 202: 150-157
• 56 Blackwell KE, Ross DA, Kapur P, Calcaterra TC. Propofol for maintenance of general anesthesia: a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol 1993; 14: 262-266
• 57 Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg 2006; 103: 1018-1025
• 58 Hu S, Zhang ZY, Hua YQ et al. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a meta-analysis. J Bone Joint Surg Br 2009; 91: 935-942
• 59 Choi WS, Samman N. Risks and benefits of deliberate hypotension in anaesthesia a systematic review. Int J Oral Maxillofac Surg 2008; 37: 687-703
• 60 Habler O. Controlled hypotension. Anaesthesist 2000; 49: 687-689
• 61 Pierce V, Kendrick P. Ischemic optic neuropathy after spine surgery. AANA J 2010; 78: 141-145
• 62 Farnham SB, Webster TM, Herrell SD, Smith Jr. JA. Intraoperative blood loss and transfusion requirements for robotic-assisted radical prostatectomy versus radical retropubic prostatectomy. Urology 2006; 67: 360-363
• 63 Chin JL, Srigley J, Mayhew LA et al. Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: evidentiary base. Can Urol Assoc J 2010; 4: 13-25
• 64 Maisano F, Kjaergard HK, Bauernschmitt R et al. TachoSil surgical patch versus conventional haemostatic fleece material for control of bleeding in cardiovascular surgery: a randomised controlled trial. Eur J Cardiothorac Surg 2009; 36: 708-714
• 65 Fawzy H, Elmistekawy E, Bonneau D et al. Can local application of Tranexamic acid reduce post-coronary bypass surgery blood loss? A randomized controlled trial. J Cardiothorac Surg 2009; 4: 25-25
• 66 Moumoulidis I, Martinez Del Pero M, Brennan L, Jani P. Haemostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt. Ann R Coll Surg Engl 2010; 92: 292-294
• 67 Frilling A, Stavrou GA, Mischinger HJ et al. Effectiveness of a new carrier-bound fibrin sealant versus argon beamer as haemostatic agent during liver resection a randomised prospective trial. Langenbecks Arch Surg 2005; 390: 114-120
• 68 Herrera S, Bordas JM, Llach J et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc 2008; 68: 440-446
• 69 Helal AS, Abdel-Hady E, Refaie E et al. Preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during abdominal myomectomy. Int J Gynaecol Obstet 2010; 108: 233-235
• 70 Casati V, Benussi S, Sandrelli L et al. Intraoperative moderate acute normovolemic hemodilution associated with a comprehensive blood-sparing protocol in off-pump coronary surgery. Anesth Analg 2004; 98
• 71 Terai A, Terada N, Yoshimura K et al. Use of acute normovolemic hemodilution in patients undergoing radical prostatectomy. Urology 2005; 65: 1152-1156
• 72 Bennett J, Haynes S, Torella F et al. Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial. Transfusion 2006; 46: 1097-1103
• 73 Jones SB, Whitten CW, Despotis GJ, Monk TG. The influence of crystalloid and colloid replacement solutions in acute normovolemic hemodilution: a preliminary survey of hemostatic markers. Anesth Analg 2003; 96
• 74 Singbartl K, Innerhofer P, Radvan J et al. Hemostasis and hemodilution a quantitative mathematical guide for clinical practice. Anesth Analg 2003;
• 75 Huet C, Salmi LR, Fergusson D et al. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators. Anesth Analg 1999; 89: 861-869
• 76 Carless PA, Henry DA, Moxey AJ et al. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev CD 001888 2010; 3
• 77 Steffens TG, Kohmoto T, Edwards N et al. Effects of modified ultrafiltration on coagulation as measured by the thromboelastograph. J Extra Corpor Technol
• 78 Oswald E, Streif W, Hermann M et al. Intraoperatively salvaged red blood cells contain nearly no functionally active platelets, but exhibit formation of micro-particles: results of a pilot study in orthopedic patients. Transfusion 2010; 50-50
• 79 Hansen E, Bechmann V, Altmeppen J. Intraoperative blood salvage in cancer surgery: safe and effective?. Transfus Apher Sci 2002; 27: 153-157
• 80 Waters JH, Tuohy MJ, Hobson DF, Procop G. Bacterial reduction by cell salvage washing and leukocyte depletion filtration. Anesthesiology 2003; 99: 652-655
• 81 Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105: 401-416
• 82 Liumbruno GM, Liumbruno C, Rafanelli D. Intraoperative cell salvage in obstetrics: is it a real therapeutic option?. Transfusion 2011;
• 83 Murray DJ, Pennell BJ, Weinstein SL, Olson JD. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336-342
• 84 Valeri CR, Cassidy G, Pivacek LE et al. Anemia-induced increase in the bleeding time: implications for treatment of nonsurgical blood loss. Transfusion 2001; 41: 977-983
• 85 Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion 2005; 45: 1413-1425
• 86 Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol 2008; 140: 496-504
• 87 Enriquez LJ, Shore-Lesserson L. Point-of-care coagulation testing and transfusion algorithms. Br J Anaesth 2009; 103 (Suppl. 01)
• 88 Ak K, Isbir CS, Tetik S et al. Thromboelastography-based transfusion algorithm reduces blood product use after elective CABG: a prospective randomized study. J Card Surg 2009; 24: 404-410
• 89 Sperry JL, Ochoa JB, Gunn SR et al. An FFP:PRBC transfusion ratio ≥1:1,5 is associated with a lower risk of mortality after massive transfusion. J Trauma
• 90 Zink KA, Sambasivan CN, Holcomb JB et al. A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg 2009; 197: 565-570
• 91 Duchesne JC, Islam TM, Stuke L et al. Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. J Trauma 2009; 67: 33-37
• 92 Burdess A, Nimmo AF, Garden OJ et al. Randomized controlled trial of dual antiplatelet therapy in patients undergoing surgery for critical limb ischemia. Ann Surg 2010; 252: 37-42
• 93 Metzler H, Kozek-Langenecker S, Huber K. Antiplatelet therapy and coronary stents in perioperative medicine – the two sides of the coin. Best Pract Res Clin Anaesthesiol 2008; 22: 81-94
• 94 Fleisher LA et al. WRITING COMMITTEE. 2009 ACCF/AHA focused update on peri-operative beta blockade incorporated into the ACC/AHA 2007 guidelines on peri-operative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 120
• 95 Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med 2005; 257: 399-414
• 96 Metzler H, Huber K, Kozek-Langenecker S et al. Coronary stents, dual antiplatelet therapy and perioperative problems. Anaesthesist 2007; 56: 401-410
• 97 Korte W, Cattaneo M, Chassot PG et al. Perioperative management of antiplatelet therapy in patients with coronary artery disease. Joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (OGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost 2011; 105: 743-749
• 98 Savonitto S, D'Urbano M, Caracciolo M et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of bridging antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth 2010; 104: 285-291
• 99 Choi WS, Irwin MG, Samman N. The effect of tranexamic acid on blood loss during orthognathic surgery: a randomized controlled trial. J Oral Maxillofac Surg 2009; 67: 125-133
• Ralley FE, Berta D, Binns V et al. One intraoperative dose of tranexamic acid for patients having primary hip or knee arthroplasty. Clin Orthop Relat Res 2010; 468: 1905-1911
• Henry D, Carless P, Fergusson D, Laupacis A. The safety of aprotinin and lysine-derived antifibrinolytic drugs in cardiac surgery: a meta-analysis. CMAJ 2009; 180: 183-193
• Murkin JM, Falter F, Granton J et al. High-dose tranexamic acid is associated with nonischemic clinical seizures in cardiac surgical patients. Anesthesia & Analgesia 2010; 110: 350-353
• Habler O, Meier J, Pape A et al. Perioperative Anämietoleranz. Anaesthesist 2006; 55: 1142-1156
• Meier J, Kemming G, Meisner F et al. Hyperoxic ventilation enables hemodilution beyond the critical myocardial hemoglobin concentration. Eur J Med Res 2005;
• Gombotz H, Rigler B, Matzer C et al. 10 years' experience with heart surgery in Jehovah's witnesses. Anaesthesist 1989; 38: 385-390
• Habler O, Voss B. Perioperative management of Jehovah's Witness patients. Special consideration of religiously motivated refusal of allogeneic blood transfusion. Anaesthesist 2010; 59: 297-311
• Hogue Jr. CW, Goodnough LT, Monk TG. Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion 1998; 38: 924-931
• Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med 1993; 21: 860-866
• Aronson D, Dann EJ, Bonstein L et al. Impact of red blood cell transfusion on clinical outcomes in patients with acute myocardial infarction. Am J Cardiol 2008; 102: 115-119
• Mantilla CB, Wass CT, Goodrich KA et al. Risk for perioperative myocardial infarction and mortality in patients undergoing hip or knee arthroplasty: the role of anemia. Transfusion 2011; 51: 82-91
• Spahn DR, Zollinger A, Schlumpf RB et al. Hemodilution tolerance in elderly patients without known cardiac disease. Anesth Analg 1996; 82: 681-686
• Grover M, Talwalkar S, Casbard A et al. Silent myocardial ischaemia and haemo-globin concentration: a randomized controlled trial of transfusion strategy in lower limb arthroplasty. Vox Sang 2006; 90: 105-112
• Spahn DR, Seifert B, Pasch T, Schmid ER. Effects of chronic beta-blockade on compensatory mechanisms during acute isovolaemic haemodilution in patients with coronary artery disease. Br J Anaesth 1997; 78: 381-385
• Spahn DR, Schmid ER, Seifert B, Pasch T. Hemodilution tolerance in patients with coronary artery disease who are receiving chronic beta-adrenergic blocker therapy. Anesth Analg 1996; 82: 687-694
• Spahn DR, Seifert B, Pasch T, Schmid ER. Haemodilution tolerance in patients with mitral regurgitation. Anaesthesia 1998; 53: 20-24
• Beattie WS, Wijeysundera DN, Karkouti K et al. Acute surgical anemia influences the cardioprotective effects of beta-blockade: a single-center, propensity-matched cohort study. Anesthesiology 2010; 112: 25-33
• Cromheecke S, Lorsomradee S, Van der Linden PJ, De Hert SG. Moderate acute isovolemic hemodilution alters myocardial function in patients with coronary artery disease. Anesth Analg 2008; 107: 1145-1152
• Beguin C, Closon MC, Vandekerckhove P, Baele P. Concentration of transfusion resources on a few pathologies and a few patients: analysis of the comprehensive in-hospital patient database. Transfusion 2007; 47: 217-227
• Cabrales P, Intaglietta M, Tsai AG. Transfusion restores blood viscosity and reinstates microvascular conditions from hemorrhagic shock independent of oxygen carrying capacity. Resuscitation 2007; 75: 124-134
• Dani C, Pratesi S, Fontanelli G et al. Blood transfusions increase cerebral, splanchnic, and renal oxygenation in anemic preterm infants. Transfusion 2010;
• Grant MJ, Huether SE, Witte MK. Effect of red blood cell transfusion on oxygen consumption in the anemic pediatric patient. Pediatr Crit Care Med 2003; 4: 459-464
• Vuille-Lessard E, Boudreault D, Girard F et al. Red blood cell transfusion practice in elective orthopedic surgery: a multicenter cohort study. Transfusion 2010; 50: 2117-2124
• Carson JL, Terrin ML, Barton FB et al. A pilot randomized trial comparing symp-tomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion 1998; 38: 522-529
• Orlov D, O'Farrell R, McCluskey SA et al. The clinical utility of an index of global oxygenation for guiding red blood cell transfusion in cardiac surgery. Transfusion 2009; 49: 682-688
• Rosencher N, Kerkkamp HE, Macheras G et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003; 43: 459-469
• Snyder-Ramos SA et al. investigators of the Multicenter Study of Perioperative Ischemia MRG. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion 2008; 48: 1284-1299
• Hill SR, Carless PA, Henry DA et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev CD 002042 2002;
• American Society of Anesthesiologists Task Force on Perioperative Blood Trans-fusion and Adjuvant Therapies.. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006; 105: 198-208
• Ferraris VA, Ferraris SP, Saha SP et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83 (Suppl. 05)
• Napolitano LM, Kurek S, Luchette FA et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37: 3124-3157
• Anker SD, Voors A, Okonko D et al. Prevalence, incidence, and prognostic value of anaemia in patients after an acute myocardial infarction: data from the OPTIMAAL trial. Eur Heart J 2009; 30: 1331-1339
• McGill JB, Bell DS. Anemia and the role of erythropoietin in diabetes. J Diabetes Complications 2006; 20: 262-272
• Wexler D, Silverberg D, Sheps D et al. Prevalence of anemia in patients admitted to hospital with a primary diagnosis of congestive heart failure. Int J Cardiol 2004; 96: 79-87
• Weiss G, Goodnough LT. Anemia of chronic disease. New England Journal of Medicine 2009; 352: 1011-1023
• Shander A. Surgery without blood. Crit Care Med 2003; 31 (Suppl. 12)
• Poldermans D, Bax JJ, Boersma E et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009; 30: 2769-2812