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An Analysis of Blood Management in Patients Having a Total Hip or Knee Arthroplasty*

BENJAMIN E. BIERBAUM, M.D., CHESTNUT HILL, MASSACHUSETTS, JOHN J. CALLAGHAN, M.D., IOWA CITY, IOWA, JORGE O. GALANTE, M.D., D.M.SC., CHICAGO, ILLINOIS, HARRY E. RUBASH, M.D.#, BOSTON, MASSACHUSETTS, ROBERT E. TOOMS, M.D.**, MEMPHIS, TENNESSEE and RICHARD B. WELCH, M.D., SAN FRANCISCO, CALIFORNIA

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty. A total of 9482 patients (3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement) were evaluated prospectively from September 1996 through June 1997. Of those patients, 4409 (46 percent [57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement]) had a blood transfusion. Two thousand eight hundred and ninety patients (66 percent) received autologous blood, and 1519 patients (34 percent) received allogenic blood. Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood. Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood; however, inefficiencies in the procedures for obtaining autologous blood were identified. Sixty-one percent (5741) of the patients had predonated blood for autologous transfusion, but 4464 (45 percent) of the 9920 units of the predonated autologous blood were not used. Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units. Of the 5741 patients who had predonated blood, 503 (9 percent) needed a transfusion of allogenic blood. The frequency of allogenic blood transfusion varied with respect to the type of operative procedure (revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions) and with a baseline hemoglobin level of 130 grams per liter or less. Transfusion of allogenic blood was also associated with infection (p 0.001), fluid overload (p 0.001), and increased duration of hospitalization (p 0.01). These latter findings warrant further evaluation in controlled studies.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
The blood loss that accompanies a total hip or knee arthroplasty can be substantial, and many patients need perioperative transfusion with allogenic or autologous blood^15,29. The potential health risks associated with allogenic blood, including the transmission of blood-borne infections such as those caused by the human immunodeficiency virus and hepatitis viruses^7,23, transfusion-related and allergic reactions⁵, and immunomodulatory effects^2-5, have led to changes in perioperative blood-management practices. Alternatives to allogenic blood transfusion, such as perioperative blood salvage^19,27, hemodilution¹⁷, and preoperative donation of blood for autologous transfusion^1,22,24, are currently being used to meet the transfusion needs of patients having an elective orthopaedic procedure. Among these alternatives, transfusion of autologous blood is perhaps the most widely used method of blood replacement^7,15,20,25. Preoperative donation of blood for autologous transfusion has become a routine practice for patients who are scheduled to have an orthopaedic procedure, unless there is a specific contraindication^7,28. However, transfusion of autologous blood is not without its drawbacks¹. Preoperative donation can be logistically difficult, time-consuming, and expensive for the patient. The greater administrative costs associated with autologous donation can make the overall cost per unit of autologous blood higher than that for allogenic blood^9,11. Phlebotomy-induced anemia is also a possibility in patients who donate blood for autologous transfusion, and it may increase the likelihood of a transfusion because of a low hemoglobin level. Finally, administrative errors associated with transfusions of autologous blood have been documented^13,21.

The purpose of the present prospective evaluation was to determine the factors that were predictive of transfusion and to document the usage and waste of predonated blood as well as any complications associated with transfusion in a large number of patients who were having a total hip or knee arthroplasty. The study was designed to determine the utilization of blood (both autologous and allogenic) after total hip and knee replacements, to document the amount of autologous blood wasted after these procedures, to define a preoperative hemoglobin level that predicts the need for blood after these procedures, and to document any other complications associated with transfusion after these procedures.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Patients who were scheduled to have a total hip or knee arthroplasty during the ten-month period from September 1996 through June 1997 were asked to participate in our study. Logistic regression analysis was used to evaluate independently the effects of several perioperative variables on the receipt of blood. It was calculated that a sample of 9318 patients was necessary to provide sufficient statistical power. Three hundred and thirty orthopaedic surgeons who were based in communities and hospitals at 235 sites in the United States enrolled patients in the study. The protocol, survey, and consent forms were approved by the Western Institutional Review Board, a central institutional review board in Olympia, Washington; thus, approvals from individual institutional review boards were not required. However, in some instances, individual institutions required approval from a local institutional review board. These approvals were managed between the site and the local review board. Written informed consent was obtained from each patient before enrollment.

The baseline hemoglobin level was measured at the time that the patient consented to participate in the study (the baseline level), before the patient donated blood for autologous transfusion (if the patient did so), and before admission to the hospital for the arthroplasty. A finger-prick sample (capillary blood) was obtained in the surgeon's office, and the concentration of hemoglobin was determined with use of a blood hemoglobin photometer (HemoCue; HemoCue AB, Agelholm, Sweden). If a HemoCue was not available, a venous blood sample (five milliliters) was drawn and the concentration of hemoglobin was determined by a local laboratory.

Preoperative data that were collected included the age, gender, and weight of the patient; the preadmission hemoglobin level, hematocrit, prothrombin time, partial prothrombin time, and platelet count; comorbid conditions, especially anemia (the definition was based on the judgment of the clinician), hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, rheumatoid arthritis, and other chronic or hematological conditions; use of relevant medications (especially iron, aspirin, nonsteroidal anti-flammatory drugs, corticosteroids, anticoagulants and diuretics); and, if applicable, the number of units of predonated autologous blood. If available, the concentration of hemoglobin measured just before the predonation of blood was noted. Intraoperative data that were collected included a description of the operative procedure (primary, revision, or bilateral total knee arthroplasty or primary or revision total hip arthroplasty), the type of anesthesia (regional, hypotensive, or general), the duration of the procedure, the estimated intra-operative blood loss, the reinfusion of salvaged blood, and the number of units and the type of red-blood-cell transfusion (autologous or allogenic, or both) that were needed. Postoperative data that were collected included the use of postoperative salvage reinfusion, the number of units and the type of red-blood-cell transfusion that were needed, and complications. Complications were reported spontaneously by the surgeons involved in the study and included wound, urinary-tract, pulmonary, or other infection; fluid overload necessitating the use of a diuretic; and deep-vein thrombosis. The duration of hospitalization was also determined. The postoperative period for data collection ended on the date of discharge.

Statistical Methods
The ordered logistic regression model was used to assess the relationship between possible predictive variables and the number of units of allogenic blood that had been transfused. The predictive variables assessed were the age and weight of the patient, the baseline hemoglobin level, the use of aspirin, coronary artery disease, anemia, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, a hematological condition, rheumatoid arthritis, intraoperative or postoperative blood salvage, regional anesthesia, hypotensive anesthesia, general anesthesia, the number of units of predonated autologous blood, the duration of the operation, and the duration of the hospitalization. The data were stratified by the type of operative procedure (primary total hip, revision total hip, primary total knee, revision total knee, and bilateral total knee arthroplasty). The patients managed with each type of procedure were evaluated separately. All variables were included in the logistic regression model as possible predictors of the number of units of allogenic blood used for transfusion. The best ordered logistic regression model was selected for each type of procedure separately, with use of backward selection of significant predictors of the number of units of allogenic blood used for transfusion. A p value of less than 0.05 was considered to be significant. The SAS Logistic Procedure (SAS Institute, Cary, North Carolina), with the backward selection option, was used to fit and select the best logistic regression model. The predictive ability of the model was also assessed with use of Kendall tau, a nonparametric rank correlation index. Odds ratios were calculated as a measure of the association between the transfusion of allogenic blood and each predictive variable. The odds ratio is the ratio of the probability of allogenic blood transfusion occurring among the patients who had the predictive variable to the probability of such a transfusion among the patients who did not have the predictive variable. An odds ratio of 1.0 indicated no association. The farther the odds ratio was from 1.0, the greater the association between two events. Chi-square tests were used to evaluate the relationship between the use of transfusions and infection, the use of diuretics, transfusion reactions, and the duration of hospitalization. P values were adjusted for multiple comparisons.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
A total of 9482 patients were evaluated (Table I). Most patients had a primary unilateral arthroplasty of the knee (49 percent) or of the hip (33 percent). Fifty-nine percent of the patients were women, and the mean age of all patients was 66.6 years. The patients who had a hip replacement were slightly younger (mean age, 64.4 years) than those who had a knee replacement (mean age, 67.6 years). Hypertension was a comorbid condition in approximately one-half of the patients. Other comorbidities included coronary artery disease (16 percent), rheumatoid arthritis (13 percent), diabetes mellitus (11 percent), anemia (7 percent), chronic obstructive pulmonary disease (7 percent), and a hematological condition (1 percent). Fifteen percent of the patients used aspirin.

View larger version (25K): [in this window] [in a new window]   FIG1: Fig. 1 Chart showing the percentage of patients who received a transfusion of autologous or allogenic blood according to the baseline hemoglobin level. Data are presented for 8561 patients because the baseline hemoglobin value was unavailable for 921 patients. No statistical analyses were performed.

Logistic Regression Analysis
We analyzed all patient-related variables (preoperative, intraoperative, and postoperative data) with use of logistic regression analysis, and we determined which variables were important independent predictors of allogenic blood transfusion. The most important variables were identified as those that were found to be significant (p < 0.05) and that had an odds ratio of at least 1.5 (Table IV).

A lack of predonated autologous blood was identified as a significant factor in all procedures (p < 0.05). This was not an unexpected finding as it is likely that most patients who had predonated blood received their own blood back, and these patients may have been previously identified by their surgeon as being at risk for transfusion of allogenic blood. To exclude this possible preselection bias, a second logistic regression analysis was performed with the exclusion of patients who had received autologous blood. The results of this regression analysis were similar to those of the first; both indicated that the number of predonated units of autologous blood and a low baseline hemoglobin level were strong predictive variables (Table IV).

Blood Management

Utilization of Autologous Blood—Wasted Units
Sixty-one percent (5741) of all 9482 patients predonated blood. The range was 47 to 70 percent according to the type of procedure. The mean donation of autologous blood was 1.7 units (range, one to five units) (Table V). Overall, almost one-half of the predonated autologous units were not used. Of the 9920 units of predonated blood, only 5456 units (55 percent) were actually given back to the patients. The unilateral primary and revision knee procedures were associated with the highest percentages of wasted units (55 percent [2302 of 4218 units] and 47 percent [172 of 365 units], respectively), and the bilateral knee and revision hip procedures were associated with the lowest percentages (29 percent [182 of 637 units] and 30 percent [260 of 857 units], respectively). Of the 5741 patients who had predonated blood, 42 percent did not receive any of the predonated blood back.

Breakthrough Transfusions
Breakthrough transfusion, which was defined as the need for allogenic blood in patients who had predonated blood, was necessary in 9 percent (503) of the 5741 patients. The prevalence of breakthrough transfusion was highest among those who had a revision hip (21 percent; ninety of 424 patients), bilateral knee (16 percent; forty-eight of 299 patients), or revision knee (11 percent; twenty-four of 223 patients) arthroplasty and lowest among those who had a primary hip (9 percent; 176 of 2063 patients) or knee (6 percent; 158 of 2696 patients) arthroplasty. The rate of breakthrough transfusion was higher in the patients who had a baseline hemoglobin level of 100 to 130 grams per liter.

Baseline Hemoglobin Level
Overall, the mean baseline hemoglobin level (and standard deviation) was higher in the patients who had predonated blood (138 ± 16 grams per liter) than in those who had not (133 ± 17 grams per liter) (p < 0.01). Before admission to the hospital, the mean hemoglobin level had decreased ten grams per liter, to 128 grams per liter, in the patients who had predonated blood. A mean of 1.7 units (range, one to five units) was predonated. In an attempt to identify a critical hemoglobin value above which the risk of transfusion of allogenic blood would be minimized, we calculated the mean hemoglogin levels of the patients who had received a transfusion of allogenic blood and those who had not received such a transfusion. Because of the association between predonation and a reduced risk of transfusion, patients who had predonated were excluded from this analysis. Of the patients for whom the baseline hemoglobin level was known, 935 who had not predonated blood and needed a transfusion of allogenic blood had had a mean baseline hemoglobin level of 123 ± 16 grams per liter and the 2565 who had not predonated blood and did not receive a transfusion of allogenic blood had had a mean baseline hemoglobin level of 137 ± 15 grams per liter. This difference was significant (p < 0.01), suggesting that patients who are not able to predonate blood should have a baseline hemoglobin level of at least 137 grams per liter to minimize the risk of transfusion of allogenic blood.

Of the 8561 patients for whom the baseline hemoglobin level was known, 3020 (35 percent) had a level of 130 grams per liter or less, with seventy grams per liter being the lowest level reported. The prevalence of allogenic transfusion was proportionately higher for the patients who had had lower baseline hemoglobin levels. Transfusion of autologous blood was performed more frequently in patients who had had higher baseline hemoglobin levels (Fig. 1).

Complications
Infections developed more frequently after the operations involving a transfusion of allogenic blood (7 percent; 105 of 1519 patients) than they did after the operations that did not involve a transfusion (3 percent; 170 of 5073 patients) (p 0.001) (Table VII). In particular, the risk of an infection of the urinary tract was higher when an allogenic transfusion had been done (3 percent; forty-six of 1519 patients) than it was when a transfusion had not been done (2 percent; 102 of 5073 patients) (p = 0.015). The risk of infection after the operations that involved a transfusion of autologous blood (4 percent; 123 of 2890 patients) was not significantly higher than the risk after operations that did not involve a transfusion (3 percent; 170 of 5073) (p = 1.04). Similarly, fluid overload necessitating use of a diuretic occurred more frequently when an allogenic transfusion had been done (8 percent; 120 of 1499 patients) than it did when a transfusion had not been done (4 percent; 192 of 4991 patients) (p 0.001); however, we detected no such association with transfusion of autologous blood (5 percent [150 of 2837 patients] compared with 4 percent [192 of 4991 patients]) (p = 0.10). No significant associations between either autologous (p = 1.0) or allogenic (p = 0.16) transfusion and thrombotic events could be detected.

Duration of Hospitalization
The patients who had received a transfusion of only allogenic blood had the longest mean duration of hospitalization (6.6 days). It was at least one day longer than that for the patients who had had a transfusion of autologous blood (5.6 days) and that for the patients who had had no transfusion (5.4 days).

Because we recognized that many variables contribute to the duration of hospitalization, a regression analysis was performed to isolate further the relationship between blood transfusion and the duration of hospitalization. Three hundred and sixty-one separate variables, including 315 separate variables that captured surgeon and site variation, were included in this analysis (Table VIII). While controlling for these 361 variables, the mean duration of hospitalization was recalculated. The association between blood transfusion and the duration of hospitalization was still apparent. Patients who had had a transfusion of allogeneic blood had the longest hospital stay (mean, 6.2 days), which was one day longer than that for the patients who had not had a transfusion (mean, 5.2 days) (p 0.01).

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
The present study represents a chronology of blood usage after primary and revision total hip and knee arthroplasty. In a retrospective analysis of 299 patients who had a total hip arthroplasty at the Mayo Clinic in Rochester, Minnesota, Nuttal et al. noted that the preoperative hemoglobin concentration was a strong indicator of the need for a transfusion of allogenic blood¹⁸. Attempting to devise an operative blood order equation to optimize blood utilization practices, those authors acknowledged that additional prospective studies were necessary. The present study involved the prospective collection of data on patient-related characteristics (including baseline hemoglobin levels) and perioperative events until the time of discharge. A sample of 9318 patients was determined to be necessary to provide statistical power for the ordered logistic regression model with five primary stratification variables (types of total joint arthroplasty) used in the analysis. The results of the present study can be considered meaningful because data on 9482 patients who had been managed by 330 surgeons in various geographic locations across the United States were prospectively collected. The study took place over a relatively short (ten-month) and recent time-interval (from September 1996 through June 1997), which minimized any influence of changing health-care practices on outcomes.

The weaknesses of the present study include the nonrandomized design, which did not allow for rigorous control of perioperative variables such as demographics and comorbidities. There was no standard protocol for proceeding with a transfusion. The prevalence of negative outcomes was determined on the basis of the surgeons' spontaneous reports, without standardized criteria; therefore, there were intrasurgeon differences in reporting these outcomes and it is likely that the reported rates are underestimates. In addition, issues that were not addressed in the present study include the possible exclusion of certain patients because of a risk of bleeding or other complications and the effect of the period of time between the donation of blood and the operation on the preoperative hematocrit and the need for transfusion of allogenic blood.

The findings of the present study confirm that allogenic blood is still being transfused despite extensive use of predonated autologous blood. Twenty percent (796) of the 3920 patients who had a procedure on the hip and 13 percent (723) of the 5562 patients who had a procedure on the knee had a transfusion of allogenic blood. Consistent with previous findings¹⁶, the rates of transfusion of allogenic blood were highest for the patients who had a revision or a bilateral procedure and for those who had a baseline hemoglobin level of 130 grams per liter or less.

The logistic regression analysis in the present study provides important insight into the issue of exposure to allogenic blood at the individual patient level. The variables that most consistently predicted the transfusion of allogenic blood in all of the procedures (with the exception of bilateral knee arthroplasty) were a low baseline hemoglobin concentration and a lack of predonated autologous blood. Both variables were negatively associated with the transfusion of allogenic blood. For example, the lower the baseline hemoglobin level, the more probable a transfusion of allogenic blood. Our findings with respect to the hemoglobin level confirm those of earlier studies in which the preoperative hemoglobin level was found to be highly predictive of the need for perioperative blood transfusion in orthopaedic patients^1,16,18. However, to our knowledge, we were the first to ensure that the baseline hemoglobin level was measured before the patient had predonated the first unit of autologous blood. As expected, the number of predonated units of autologous blood was also negatively associated with transfusion of allogenic blood because patients who predonate more blood are expected to receive fewer units of allogenic blood. A mean of 1.7 units of blood was predonated by each patient, and 61 percent (5741) of the 9482 patients predonated blood. This rate of predonation was higher than that previously reported for orthopaedic patients^18,25 and probably reflects a number of different factors, including the increased awareness by physicians and patients of the risks associated with transfusion of allogenic blood.

The results of the present study highlight the inefficiency of the collection and use of autologous blood. A high percentage of the autologous units were discarded, and many patients never received any of their predonated autologous units; thus, there was the problem of overcollection. At the same time, there was the problem of undercollection: that is, a number of patients were not protected from exposure to allogenic blood despite predonation. Overcollection of autologous units has been documented in the literature^9,26. Etchason et al. reported that autologous blood has a higher incremental cost than allogenic blood because of the practice of discarding unused autologous units and the more labor-intensive process involved in the collection, identification, and storage of autologous units⁹. Autologous units are not routinely contributed to the general blood supply because of the less stringent standards used for testing autologous blood and for documenting the past history of the patient donating it. The results of a 1989 survey of blood collection in the United States showed that only 356,000 (54 percent) of 655,000 units of predonated blood were transfused back to the patients²⁶. That study was not restricted to orthopaedic patients; however, comparison of those findings with our results indicates that the problem of wasted autologous blood has not diminished.

Serious inefficiencies in the selection of patients were reflected by the rate of breakthrough transfusion—that is, the percentage of the patients who had predonated autologous blood but also needed allogenic blood. The rate of breakthrough transfusion ranged from 6 to 21 percent according to the type of procedure and was highest for the patients who had a revision hip arthroplasty. Breakthrough transfusion represents a clinical situation in which a patient is physically unable to donate a sufficient number of units or has become iatrogenically anemic in the process of donation. The rate of breakthrough transfusion for all procedures was highest for the patients who had had a baseline hemoglobin level that was between 100 and 130 grams per liter; this finding suggests that patients who have a hemoglobin level of 130 grams per liter or less need more extensive preoperative planning for their blood management. Such patients should be counseled with respect to their potential need for postoperative transfusion of allogenic blood, and intervention with pharmacological agents such as erythropoietin should be considered^6,8,10,12,14.

The outcomes analysis performed in our study demonstrated that allogenic blood transfusions are associated with a higher rate of complications (fluid overload and infection) and an increased duration of hospitalization. Additional, controlled studies are warranted to verify these results.

In summary, the results of the present study demonstrate that the baseline hemoglobin level was a consistent predictor of allogenic blood transfusion and that the use of predonated autologous blood was inefficient. Given that the baseline hemoglobin level can be used to predict the need for transfusion of allogenic blood, the present study supports the strategy of reducing the number of units of blood predonated by patients who have a higher baseline hemoglobin level. At the same time, there appears to be a baseline hemoglobin value at which predonation becomes ineffective; this is manifested by an exacerbation of anemia and an increase in breakthrough transfusion of allogenic blood. This phenomenon occurred primarily in patients who had a baseline hemoglobin level of 130 grams per liter or less. Considering the time and cost associated with the donation of blood for autologous transfusion, strategies for more cost-effective blood management should be investigated.

	Footnotes

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Biesma, D. H.; Marx, J. J. M.; and and Van De Wiel, A.: Collection of autologous blood before elective hip replacement. A comparison of the results with the collection of two and four units. J. Bone and Joint Surg., 76-A: 1471-1475, Oct. 1994.[Abstract/Free Full Text]

2. Blumberg, N.; Heal, J. M.; Murphy, P.; Agarwal, M. M.; and and Chuang, C.: Association between transfusion of whole blood and recurrence of cancer. British Med. J., 293: 530-533, 1986.

3. Blumberg, N., and and Heal, J. M.: Evidence for plasma-mediated immunomodulation—transfusions of plasma-rich blood components are associated with a greater risk of acquired immunodefienciency syndrome than transfusions of red blood cells alone. Transplant. Proc., 20: 1138-1142, 1988.[Medline]

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6. Canadian Orthopedic Perioperative Erythropoietin Study Group: Effectiveness of perioperative recombinant human erythropoietin in elective hip replacement. Lancet, 341: 1227-1232, 1993.[Medline]

7. Cone, J.; Day, L. J.; Johnson, G. K.; Murray, D. G.; and Nelson, C. L.: Blood products: optimal use, conservation, and safety. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 39, pp. 431-434. Park Ridge, Illinois, American Academy of Orthopaedic Surgeons, 1990.

8. De Andrade, J. R.; Jove, M.; Landon, G.; Frei, D.; Guilfoyle, M.; and and Young, D. C.: Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopedic surgery patients. Am. J. Orthop., 25: 533-542, 1996.[Medline]

9. Etchason, J.; Petz, L.; Keeler, E.; Calhoun, L.; Kleinman, S.; Snider, C.; Fink, A.; and and Brook, R.: The cost effectiveness of preoperative autologous blood donations. New England J. Med., 332: 719-724, 1995.[Abstract/Free Full Text]

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12. Goldberg, M. A.; McCutchen, J. W.; Jove, M.; Di Cesare, P.; Friedman, R. J.; Poss, R.; Guilfoyle, M.; Frei, D.; and and Young, D.: A safety and efficacy comparison study of two dosing regimens of epoetin alfa in patients undergoing major orthopedic surgery. Am. J. Orthop., 25: 544-552, 1996.[Medline]

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19. Semkiw, L. B.; Schurman, D. J.; Goodman, S. B.; and and Woolson, S. T.: Postoperative blood salvage using the Cell Saver after total joint arthroplasty. J. Bone and Joint Surg., 71-A: 823-827, July 1989.[Abstract/Free Full Text]

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25. Toy, P. T. C. Y.; Strauss, R. G.; Stehling, L. C.; Sears, R.; Price, T. H.; Rossi, E. C.; Collins, M. L.; Crowley, J. P.; Eisenstaedt, R. S.; Goodnough, L. T.; Greenwalt, T. J.; Johnston, M. F. M.; Kennedy, M. S.; Lenes, B. A.; Lusher, J. M.; Mintz, P. D.; Patten, E. D.; Simon, T. L.; and and Westphal, R. G.: Predeposited autologous blood for elective surgery. New England J. Med., 316: 517-520, 1987.[Abstract]

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