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LAB WORK: Use low volume blood draw for lab specimens

• CBC before starting Erythropoietin if current Hgb & Hct more than 3 days old.
• Serum Iron, TIBC, and ferritin level, should be drawn before starting Erythropoietin and/or Iron administration. 

MEDICATIONS:

• Folic Acid 2 mg PO daily
• Vitamin C 500 mg PO daily
• Vitamin B-12 (cyanocobalaminâ) 1000 micrograms deep subcutaneous injection for one dose (if indicated)
• Ferrous sulfate 325 mg PO three times a day (if taking calcium; iron should be give 2 hours before or after calcium doses)
• If patient unable to tolerate PO iron or TSAT% > 20 please consider IV iron therapy – see IV iron order set
• Erythropoietin (EPO) 40,000 units subcutaneously weekly (Days 21,14, and 7 prior to surgery)*
    Dose # 1 – 21 days prior to scheduled surgery                
    Dose # 2 – 14 days prior to scheduled surgery
    Dose # 3 – 7 days prior to scheduled surgery  
    Dose # 4 – day of surgery – dose will be on pre-op order set

*Due to a recent black box warning erythropoeitin should not be used in patients whose Hgb is > 12 mg/dL.  (If patient’s Hgb is > 12mg/dL the patient should sign an informed consent provided by FMC’s Legal department prior to receiving Erythropoietin.  Erythropoietin is indicated for the treatment of anemic patients (hemoglobin between 10 and 12 grams/deciliter) scheduled to undergo elective, noncardiac, nonvascular surgery to reduce the need for allogeneic blood transfusions, or for patients at high risk for perioperative transfusions with significant, anticipated blood loss (>500 mL).

For IV Iron Infusions guidelines see IV Iron Infusion Order Set

IP=Inpatient Administration; OP=Outpatient Administration (Hospital based Outpatient Day/Infusion Center)

HEMATOLOGIC AGENTS

Red Blood Cells

• Hematinics.  Iron, folic acid, and vitamin B12 are essential nutrients for red blood cells.         
• Recombinant Erythropoietin (r-Hu-EPO).  r-Hu-EPO is a biosynthetic form of a natural human hormone responsible for stimulation of red blood cell production.
• Darbepoetin alfa – (DPO) is an erythropoiesis stimulating protein, closely related to erythropoietin.

White Blood Cells

• Recombinant Granulocyte-Colony Stimulating Factor (r-Hu-G-CSF).  This medication is a biosynthetic form of a natural human hormone that stimulates production of neutrophils (a specific type of infection-fighting white blood cell) in the bone marrow.  It is manufactured using recombinant DNA technology, and has the same biological effects as endogenous human granulocyte colony-stimulating factor.
• Recombinant Granulocyte Macrophage-Colony Stimulating Factor (r-Hu-GM-CSF).   This is a biotechnologically produced form of a naturally occurring human hematopoietic agent.  It stimulates production of a variety of infection-fighting white blood cells (neutrophils/granulocytes and monocytes/macrophages).

Platelets

• Recombinant Interleukin-11 (r-Hu-IL-11).   Interleukin-11 is a genetically produced form of a naturally occurring human hormone that stimulates the body's platelet production.
• Recombinant Thrombopoietin (r-Hu-TPO), Megakaryocyte Growth and Development Factor (r-Hu-MGDF).   These drugs stimulate platelet production.  They are synthetic versions of a natural human hormone produced by recombinant DNA technology.  The effect of r-Hu-TPO on platelet production is analogous to erythropoietin (r-Hu-EPO) in stimulating red blood cell production.

HEMOSTATIC AGENTS

• Aminocaproic Acid  
• Tranexamic Acid
• Aprotinin
• Desmopressin
• Topical Hemostatic Agents  
• Tissue Adhesives
• Vitamin K (Phytonadione)

RECOMBINANT ANTIHEMOPHILIC FACTORS

• Recombinant Factor VIIa
• Recombinant Factor VIII.  
• Recombinant Factor IX

NONBLOOD VOLUME EXPANDERS

• Crystalloids         
• Colloids  pentastarch, hetastarch, gelatin, and dextran.

BLOOD CONSERVATION DEVICES AND EQUIPMENT

Hemostatic Surgical Instruments

• Electrocautery.  The heated probe cauterizes capillary vessels and small arteries, thus minimizing blood loss during surgery. 
• Lasers.  Cutting is achieved hemostatically, making the systems suitable for endoscopic and open-surgical procedures.  Lasers promote clotting by localizing heat in bleeding vessels, resulting in coagulation.
• Microwave Scalpels  Microwaves are a form of electromagnetic energy that can be used to generate heat. 
• Argon-Beam Coagulator Argon-beam coagulation may be used for the hemostasis of surface, diffuse bleeding from parenchymatous tissues (e.g., of the liver, spleen).

MINIMALLY INVASIVE SURGERY

An approach to surgery whereby operations are performed with specialized instruments designed to be inserted into the patient through small incisions or natural body openings.  This avoids the need for large incisions, minimizing the bleeding and trauma of surgery to the body.  Miniaturized telescope like devices allow surgeons to watch their actions on a television monitor, instead of looking directly at the part of the body being treated.

• Endoscopy.   Endoscopes allow visual examination of the interior of the stomach, intestines, and other body cavities.  Bleeding or other problems can be located, diagnosed, and treated without conventional open surgery.         
• Laparoscopy.   Using a small "keyhole" incision, a laparoscope may be used to visualize the abdomen.  Specialized instruments and techniques adapted for minimally invasive surgery may be inserted through other nearby small unobtrusive incisions to perform surgical interventions.
• Robotic Surgery. This allowssurgeons to perform minimally-invasive procedures as if they were performing open surgery, but with reduced bleeding, less pain, smaller risk of internal scarring, shorter hospital stay and a shorter recovery.

BLOOD RECOVERY/SALVAGE DEVICES

Awareness of the need for blood conservation in the surgical patient and concerns about the risks of allogeneic blood transfusion have prompted clinicians to make wider use of the autologous blood recovery techniques.  Modern intraoperative and postoperative autotransfusion is considered to be safe, well-tolerated, and cost-effective for a variety of patients with profuse bleeding.

• Intraoperative Blood Salvage/Recycling Devices (Autotransfusion).  Autologous blood cell salvage (autotransfusion) involves recovery of some portion of the patient's shed blood from a wound or body cavity, washing or filtering, and reinfusion of the blood into the patient.  Reinfusion can be performed continuously during surgery.         

MINIMALLY AND NONINVASIVE BLOOD DIAGNOSTIC AND MONITORING SYSTEMS

Blood Microsampling.  Microsample blood analysis devices use electrochemical, photometric and other technology to provide immediate critical diagnostic information at the point of care from only a few drops of blood (a fraction of the usual quantity).  This reduces cumulative blood losses, as well as the time required to make decisions on patient management that are dependent on the results of blood tests.

Blood Low Volume Sampling: Low volume sample blood analysis use smaller amounts of blood to provide critical diagnostic information using less than the usual quantity of blood.   This reduces cumulative blood losses, as well as the time required to make decisions on patient management that are dependent on the results of blood tests.

Reduction of “waste” blood with Drawbacks: When patients need to have blood removed from existing intravenous lines due to difficulty with vein access or frequency of draws, the staff collecting the blood sample should utilize devices that waste the least amount of blood as possible (i.e. Abbott SafeSets^®). This allows for the reinfusion of the “waste” blood into the patient. This prevents a large amount of wastage of blood, and also supplies the patient with a clean blood sample that is not contaminated with IV solution or medications that may have been in the IV line. 

Lab work to be requested:

CBC and Serum iron profile with ferritin level drawn before Erythropoietin and Iron administration and repeated every 3 days while on therapy

AUTOLOGOUS TECHNIQUES

The broad categories of autologous techniques are (1) preoperative blood donation and storage (see Preoperative Techniques), (2) intraoperative and postoperative blood cell recovery (see Blood Recovery/Salvage Devices), and (3) intraoperative hemodilution.

Preoperative Autologous Blood Donation (PABD).   Predonation and storage of a patient's own blood a few weeks before elective surgery for transfusion during or after surgery, if it is required. 

Hemodilution.  A technique whereby several units of blood are collected from a patient immediately before surgery and replaced with a nonblood volume expander.  Although bleeding during surgery remains unchanged, any blood loss during the surgical procedure contains fewer red cells because the patient's blood has been diluted. At the conclusion of surgery, collected blood can returned to the patient.