Effectiveness and safety of erythropoiesis-stimulating agent use in the perioperative period

Abstract

Current evidence supports the use of perioperative ESAs to reduce the need for ABT. However, large studies assessing safety in anemic patients with chronic renal disease have found adverse effects including cardiovascular, stroke and thromboembolic events. However, whether these concerns can be conferred onto the surgical population remains to be seen as the perioperative dosing strategies have been more variable in timing, dose and duration in comparison with those used for chronic diseases. Future research needs to address the questions of optimal dosing strategies in order to maximize the positive effects and minimize adverse events.

Minimizing transfusion requirements for children undergoing craniosynostosis repair: the CHoR protocol

“…10,26 Studies have reported EBL as high as 60%-100% of estimated blood volume (EBV) with almost all patients undergoing a blood transfusion during or immediately after the surgery. 16,32,34 Our results were consistent with the high EBL presented in previous studies, with a 15 ml/kg average EBL (18% EBV) for the C group and 23.5 ml/kg (29% EBV) for the protocol group. Techniques for surgical repair of craniosynostosis have the goal of achieving a long-term normocephaly while minimizing risk, including the need for transfusion.…”

“…Due to the low incidence of such events in these studies, no clear correlation with EPO treatment could be made. 13,25,27,32 A concern for EPO use is the development of thrombotic complications associated with the higher hematocrit resulting from EPO therapy. The occurrence of thrombotic events in children receiving EPO is very low (0.07-0.14 per 10,000 children in the general population).…”

“…There seems to be a low risk of precipitating hypertension during short-course preoperative EPO therapy. 32 Overall, the safety of EPO therapy in patients undergoing elective surgery has been demonstrated in more than 1000 patients in placebo-controlled trials. 13 In our study, we did not observe any side effects of EPO therapy, which is in accordance with the data available in the literature.…”

“…13 In our study, we did not observe any side effects of EPO therapy, which is in accordance with the data available in the literature. 13,22,32 Previously in our institution, the transfusion trigger was not standardized, and transfusion was often performed to maintain a hemoglobin level of 10 g/dl. In our protocol, a transfusion trigger was defined as a hemoglobin level below 7 g/dl.…”

Blood conservation strategies and the management of perioperative anaemia

“…One important point of distinction is that many studies reporting on the thromboembolic risks of ESAs are from patients with chronic renal disease, who are typically treated with higher doses over longer time, and high-risk populations such as critically ill and cancer patients [33,34], as opposed to the use of ESA in the preoperative setting, which typically involves much lower duration of treatment and lower doses often used in combination with anticoagulants [35]. Some evidence suggests treatment with ESAs to achieve arbitrary haemoglobin levels as treatment targets may result in some patients (those with ESA resistance) receiving exceedingly large doses of ESA, which may expose them to higher risk of complications [4 && ,36].…”