Firstly I am very sorry to hear about the situation with your son, it must have been a very traumatic experience for you and a very sad experience for you and your family.
I am not medically qualified and I do not know the specifics of this particular case, so you should read my comments with those facts in mind. I hope that other qualified persons will be able to provide more specific "technical" information for you with regard to EPO.
My understanding is that EPO (when used with I/V iron - typically "Venofer" in the UK) will take typically from 3 - 7 days to start to increase the volume of red blood cells and these will increase well then from 5-14+ days. This being the case it would seem that it would not be a treatment suitable for IMMEDIATE results in the field of trauma, eg road traffic accident resulting in heavy blood loss. However it might well be used with a view to increasing blood levels post-operatively, (or pre-operatively before known surgery).
In this particular situation you say that your son entered hospital with a blood count of 14, a figure which would be an acceptably normal level for a male.
On the surface this would indicate that there would have been scope for the use of intra-operative cell salvage or haemodilution, both of which would be used with the explicit intention of conserving blood. The cell-saver conserving blood shed from the surgical site during the operation and haemodilution conserving the blood immediately prior to operating by drawing off blood (which remains connected to the JW patient) and partially replacing it with a volume expanding solution, thereby having the blood available for reinfusion.
Of course, in cases of serious blood loss time is of the essence and the quicker surgical action is taken to stop the bleeding the better, often problems are caused by delay.
I do not know if you are familiar with cell-salvage but it is a mechanical means of recovering, cleaning, filtering and re-infusing blood which is "lost" at the surgical site. In effect any blood "lost" by the surgeon during the course of the operation may not need to be lost by the patient as it can be recovered by the cell-salvage equipment and then reinfused immediately into the patient. It is known that in general terms salvaged blood is MUCH more beneficial than stored blood for such use, particularly in its ability to hold and deliver oxygen.
Whilst cell-salvage is I believe widely used in the US, in the UK it is frustratingly under-used. Whilst some hospitals (eg Morriston, Swansea and Devon & Exeter) have pioneered the use of cell-salvage in the UK many hospitals when having them available do not routinely make use of them as they will often departmentalize them rather then using them hospital-wide. Progress is being made and with the recent iniciatives by the NHS Executive to force Trusts to investigate alternatives to blood transfusions, we can look forward to an increased use. As part of a local HLC we are regularly visiting hospitals to "educate" them on the use of alternatives to blood transfusion. Great improvments are being made but there will always be room for improving further. It would be true to say that in our particular area in the last 3 years we have seen dramatic improvements in non-blood facilities available to JW's and whilst this is sadly of no benefit to your son, there is perhaps some comfort to be gained in the fact that others may well be saved your loss in the future. I hope that this brief attempt at assistance may have proved useful.

EPO and Iron is of no use in an acute life or death situation. My strategy with an JW in a case like your son would include some or all of:

1. Life before limb, limberal use off tourniquet. Have the radiologic department to create an embolus in his limb to reduce the bleeding? In extremis I would considered a laparatomy with clamping the iliaca.

2. Restrictive use of fluids i.v. Accept a very low blood pressure.

3. Use of tranexamic acid! NovoSeven?

This is an very complex and diffucult case and my comments are not any critics to the threatment your son recived.

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Dr Lukas MÃ¥nsson MD
Drammen
Norway

You have to known about the kinetics off Hb in acute blood loss. First when you have an acute blood loss you will have less blood but the blood will have the same Hb. Then there will be a dilatution of the blood. Then you will increase the blood volume but decrease the Hb.

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Dr Lukas MÃ¥nsson MD
Drammen
Norway

Doctor Mansson gives a snapshot of trauma treatment. The goal is simply survival. Without life there is no need to consider future treatment modalities.

The problem: Are there things we can do during or soon after the critical stabilization phase that will have a positive and possible life-saving result when the patient reaches ICU? - Yes.

After stabilizing the patient can the trauma specialist work with the intensivist to begin a more future-looking treatment plan? Certainly. In fact an algorithm can be designed and implemented to facilitate the transition from trauma to intensive or acute care. In the case of extreme blood loss the algorithm would include blood building measures such as IV Iron and EPO.

There can be a critical delay in treatment as the patient makes the transition from the Emergency Department to the next phase of care. Since EPO takes several days to effect a change in status the sooner it starts the better. However, EPO isn't the only treatment option possible. Phasing longer term treatments into the care path ASAP is important in maintaining continuity of care.

Summary: Obviously the main focus of the trauma team is saving and stabilizing the patient. However once the patient is sufficiently stable a treatment plan including the use of EPO and IV Iron when appropriate should begin. Order sets can be created to facilitate the transition from ER to ICU. This will insure continuity in the care of the patient.

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Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
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