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Doping is the use of a substance that artificially increases an individual's physical ability for competition purpose. Products and methods used in doping are not without risk, especially at cardiovascular level. Here we review the most common doping substances in sport and their cardiovascular consequences., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

We assessed the benefit of predeposite autologous blood donation (PAD) before bone marrow (BM) donation on transfusion requirements, haemoglobin concentrations (Hb) and the occurrence of adverse events (AE). We collected data retrospectively from 50 donors of BM with PAD from 2010 to 2014. An autologous transfusion (AT) was given to 50% of the donors (group 1). In the group 2, the products from PAD were not used. The total volume median of marrow harvested was 17.7 mL/k (range 12.3-21.4) in the group 1 and 13.3 mL/k (8.6-22.6) in the group 2. The female ratio was higher in the group 1 (60%) than in the group 2 (16%). Bone marrow harvest led to a decline in Hb (from PAD to first day after BM donation) by 2.9 g/dL (1.5-5.5) in the group 1 and by 3.5 g/dL (1.2-5) in the group 2. The post-harvest Hb (D+1) median was identical in the two groups: 10.9 g/dL (7.6-13.5) in the group 1 versus 11.5 g/dL (9.3-13.4) in the group 2. Six AE were reported in each group. In the group with AE, the median weight was lower: 58 k (50-71) versus 75 k (52-110); and the median total volume of marrow harvested was higher: 20.1 mL/k (9.9-21.4) versus 14.3 mL/k (8.6-22.6). All post-harvest Hb were ≥ 7.6g/dL. This study shows the high loss of Hb after BM donation but not enough to prove a blood transfusion in BM donors with median age of 36 years (16-62) and without comorbidity. The occurrence of AE (25% of BM donors) justifies a careful surveillance after the BM donation. The PAD should not be routinely offered to bone marrow donors., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

In addition to more restrictive "transfusion triggers", presently available allogeneic blood conservation strategies in surgery include preoperative increase in red blood cells (RBC) mass, techniques or pharmaceutical agents that reduce blood loss, and perioperative blood salvage. Because of very important risk reduction in allogeneic blood, benefit/risk of preautologous blood donation (PAD) is quite questionable at this moment. Indeed, at this moment in France, we focus to avoid any transfusion (allogeneic and autologous blood). Therefore the most important techniques used are pharmacological: erythropoietin before surgery with a number of injections related to baseline Hb, and tranexamic acid during and after surgery. Cell saving is used only if bleeding is enough important like arthroplasty revisions. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics are determinant to settle a blood conservation strategy. The choice of a technique should take into account (a) the delay before surgery, (b) the anticipated blood loss for the procedure that varies among institutions, (c) the tolerable blood loss without transfusion for the patient, and (d) the efficacy of the blood conservation technique in the given setting. Nevertheless, at this moment in France, it is quite important to notice that the risk of delay or lack of transfusion induces much more deaths that the transfusion itself during or after anesthesia [Anesthesiology 105, 1087-97].

In moderately anaemic patients, Autologous Blood Donation is much less effective than Erythropoïetin (EPO) at constituting a pre-operative RBC reserve. Indeed, the ability to give blood is limited or even impossible for anaemic individuals. EPO lowers the risks associated with autologous and allogeneic transfusions, while improving probably the quality of life of the patients. EPO therapy is efficient, in moderate anaemic patients, to reduce allogeneic transfusion when iron supplementation is associated. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics, are determinant to settle a blood conservation strategy. But to optimise benefit/cost/effectiveness of this technique, it is important to take into account the delay before surgery, the anticipated blood loss for the procedure that varies among institutions and the tolerable blood loss without transfusion for the patient. To reduce the cost, a strategy according to baseline haematocrit and to blood loss has to be adapted at each patient. Furthermore, when the delay between the first EPO injection and the surgical procedure is sufficient, the number of injections can be easily reduced to obtain the same Ht the day prior to surgery.

We report the case of a 6-month-old child, who suffered from acute haemolysis following transfusion of salvaged blood. This complication, of favourable outcome, was related to the accidental aspiration of benzalkonium chloride into the cell saver. This case emphasizes that any adjunction of antiseptic solution is contraindicated during blood saving. The use of a cell saver must be associated with written protocols, describing clearly the contraindications, precautions of use, and the different steps of use of this method of autologous blood transfusion.

Objectives: Intraoperative blood cells salvage using a Cell Saver technique is controversial in oncologic surgery because tumor cells could be aspirated and reinfused to the patient. The goal of this review was to discuss the risk associated with this technique, and the way to minimize it., Data Sources: A review of the literature has been made by questioning PubMed site (http://nbci.nlm.nih.gov) on the period of 1968 to 2000. The key words were: intraoperative blood salvage, blood transfusion, autologous, cancer. Cases reports have been excluded., Study Selection: Tumor cells aspirated and reinfused have been numbered in both experimental and clinical studies. In clinical studies, the outcome after intraoperative cells salvage/reinfusion has been compared to published data or historical groups of allogeneic transfusion, all in non randomized studies., Data Synthesis: Both experimental and clinical studies confirmed the presence of cancer cells in the blood either aspirated or reinfused. However, six clinical studies with limited number of patients did not show metastatic spread associated with Cell Saver. The addition of leukocyte filters reduces greatly this quantity of cancer cells. Irradiation of the pack did not destroy tumor cells but blocked their proliferative capacity. In the other hand, some infiltrative tumors were shown to have permanent cancer cells seeding, quantitatively superior to the seeding observed when a Cell Saver is used., Conclusion: It seems reasonable to use the Cell Saver in oncologic surgery, if possible with a leukocyte filter, not only in case of unexpected major bleeding (consensus), but also in programmed cases with high risk of huge hemorrhage.

Autologous blood transfusion has been shown to decrease allogeneic transfusion in patients undergoing elective procedures, in adults as well as in children. However, its indication must be carefully discussed for each patient, since, on the one hand, viral risks associated with allogeneic blood are greatly reduced, while on the other hand, adverse events may occur in some patients with poor physical condition. An assessment of the ratio 'benefit-risk' has to be made for each patient.

Blood transfusion, like any other medical activity, requires an analysis of the risk/benefit ratio for each patient. Autologous blood transfusion does not escape this golden rule. The benefits expected of scheduled autologous transfusion consist of the reduction of the risks inherent in homologous transfusion. Those benefits are indisputable in erythrocyte alloimmunisation and viral or parasitic disease transmission. But the risks attached to such protocols have often been underestimated. The risks for the patient are still linked to the transfusion of autologous labile blood products (haemolysis, bacterial infections) or to consequences of whole blood donations (cardiovascular intolerance, increased use of transfusion, increased operative bleeding). There are also risks for the patient community insofar as autologous blood products which do not all meet the same criteria of clinical and biological validation as homologous blood products are circulated in care institutions.

In this review, we develop four topics on the relationship between blood transfusion and cancer. First, the rationale for not allowing blood donations from patients with infiltrating tumors is presented. Second, the different possibilities for autotransfusions in cancer patients are discussed. Predeposited autotransfusions are rarely possible in these patients, in addition to the high cost. The usefulness of another method, intraoperative autologous transfusion with blood saved from the surgical field, is not well established. Our third topic concerns the effect of transfusion on cancer induction. In some cases, the risk of cancer is higher after allogenic transfusion resulting from a mechanism involving alterations of the immune function. Finally, the relationship between transfusion and cancer recurrence is controversial. In spite of numerous studies attempting to elucidate this relationship, no final conclusion can be drawn at the present time. What is sure, is that patients requiring blood transfusion have a higher risk of recurrence than patients who do not need transfusion.

To verify that the rate of post operative infections is higher with homologous transfusion rather than without, 86 coronary artery bypass patient charts were retrospectively studied. Inclusion criteria were those of the autologous transfusion group. Four groups were defined : Gr 1 : No transfusion. Gr 2: Autotransfusion. Gr 3: Allotransfusion. Gr 4: Autotransfusion who also received homologous blood products. Although not significant, the bacterial infection rate was twofold higher in the Gr 3, than in the autologous group and was almost four times higher and significant (p < 0.01) when patients who received homologous blood products were compared to those who did not. These preliminary results lead us to enlarge our autotransfusion program and us encourage, to search for the cause of the decreased infection rate after autologous transfusion by prospective studies.

A secondary neuromuscular blockade can occur after transfusion of autologous blood withdrawn after injection of muscle relaxants. In this study time course of muscle relaxation after transfusion of blood withdrawn before or after administration of atracurium (A) or vecuronium (V) was assessed. Forty adults undergoing haemorrhagic urologic surgery were included in the study. After induction of general anaesthesia and intubation of the trachea facilitated by local lidocaine, they were divided into 4 groups. In groups A1 and V1 the blood units were withdrawn before injection of atracurium 0.5 mg.kg-1 or vecuronium 0.1 mg.kg-1. In group A2 and V2 the blood units were withdrawn after administration of muscle relaxants. Haematocrit was decreased to 0.30. The last bolus of these muscle relaxant was injected 30 min before the end of surgical procedure. Autologous blood was transfused when train of four (T4R) recovered to 0.80. Electromyographic elicited responses to T4R stimulation were obtained every minute during the 4 first minutes after the beginning of transfusion (T1 to T4), thereafter every minute during the 5 first minutes after the end of transfusion (T5 to T9), and finally every 5 minutes for 10 minutes (T10 and T11). There was a secondary neuromuscular blockade in patients of groups A2 and V2. The intensity of blockade was more important after vecuronium than after atracurium (p < 0.01 from T2 to T11 between groups A2 and V2). In group A2, the T4R had not reached the control level at the end of the procedure (0.78 at T11 vs 0.80 at T0). These data emphasize the importance of withdrawing blood units before administration of muscle relaxants.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between blood transfusion and cancer is considered from five points of view: 1) The cancer patient as a blood donor. Cancer must remain a cause of exclusion from blood donation. 2) Autologous blood transfusion for cancer patients. Predeposited autologous blood transfusion is only possible for a small number of patients. Intraoperative blood salvage carries with it the risk of disseminating tumor cells. 3) History of blood transfusion and the risk of having a cancer: a) the persistence of immune alterations following blood transfusion for years might expose the patient to an increased risk of having a cancer; b) blood transfusion might carry immunosuppressive viruses, and hepatitis viruses are related to the risk of liver cancer. 4) Cancer recurrence and blood transfusion. Conclusion of most of the published studies is that blood transfusion is associated with an increased risk of recurrence of colorectal cancer. The only realistic randomized study would compare different transfusion strategies (allogenic, leukocyte poor allogenic and autologous blood transfusion) to determine which is the best for cancer patients. 5) Post-transfusion GVH in cancer patients. Some cases have recently been published. They all can be explained by a particular HLA compatibility between the recipient and one of the blood donors.

Patients undergoing elective coronary bypass surgery can benefit from Preoperative Autologous Blood Donation (PAB), despite some opinions to the contrary, as a complement of intra-operative blood salvage techniques. We report herein 106 patients eligible for coronary bypass surgery included in our PAB program. We observed a very good tolerance owing to strict exclusion criteria, a close monitoring of vital signs, and as far as we are concerned, to the infusion of a macromolecular solution (Plasmion) in a 1:1 ratio, to maintain intra-vascular volume. We chose a volume replacement because the physiological adaptation to hypovolemia is altered by the beta-blocking and/or vasodilating agents which cannot be discontinued in patients with coronary heart disease. The changes in the hematological parameters are not different from those observed in other patients eligible for PAB. The postoperative hemoglobin level is satisfactory and compatible with a normal myocardial function inasmuch as the cardiopathy has been corrected. The efficiency of PAB is good since overall, 74% of the patients did not require homologous blood, this proportion rises to 84% for patients donating 3 or more units. Preoperative Autologous Blood Donation for patients with coronary heart disease implies a perfect coordination between the Blood Bank physicians and their colleagues from the Cardiology Department. Aside from its well known advantages, PAB allows a stimulation of erythropoiesis, a progressive normovolemic hemodilution perhaps beneficial to patients with coronary heart disease, and finally, a better psychological preparation to surgery.

This procedure is well known, there were 2 000 cases reported in the literature with a very small number of complications. Is autotransfusion really efficacious? According to the author's results in 9 cases of hemoperitoneum, the red cells obtained by this method are quantitatively valid, but hemolysis starts early (6 hours) and the disappearance of the platelets and coagulation factors occurs even more early (2 hours). However, clinical tolerance is perfect, thus confirming the good experimental results obtained in animals. The true limits are hemolysis and the risk of contamination but, with appropriate apparatus and precise indications, and unsoiled blood, less than 24 hours old, autotransfusion is a good method which may provide a solution in certain emergencies.

As large quantities of blood are required during orthotopic liver transplantation, intraoperative autotransfusion is therefore often carried out in adult patients. This study aimed to assess the ease of use of this technique, its efficiency and possible side-effects. Intraoperative blood salvage was carried out using a Cell Saver 4R (Haemonetics) in 14 patients. The chest blood was collected, anticoagulated with heparin and sodium citrate, centrifuged and washed with Ringer lactate. During surgery, and the subsequent 5 days, the following data were recorded: red cell and platelet count, haemoglobin concentration, parameters of renal function, potassium, citrate and fibrinogen levels, parameters of renal function, blood cultures and the extubation delay. Autotransfusion was simple to use, with no side-effects during the procedure. An average of 20.5 red cell packs were required, of which 59.2 +/- 2.3% were supplied by autotransfusion. The volume of transfused blood was similar, or inferior, to other studies. The different haematological parameters, blood gases and serum potassium levels remained stable. Only 4 +/- 2.8 red cell packs were required postoperatively to maintain a stable haematocrit value. There was no increase in thrombin time, and therefore no effect due to the used heparin. Citrate levels were correlated with the amount of autotransfused blood. They were lower than in other studies because autotransfusion limited the citrate load. There was no haemolysis. Postoperative renal function remained normal. There was no change in the blood coagulation profile, except when large volumes were transfused, resulting in a dilutional coagulopathy. Extubation was always carried out during the first two postoperative days. Bacteriological studies remained negative, no bacteraemia being noted. During orthotopic liver transplantation autotransfusion is a simple, reliable technique, with few side-effects.

Intraoperative autotransfusion was used in 15 patients undergoing peripheral vascular, porta-caval and liver surgery. This technique is blood saving in these indications. The most important physiopathological consequence is disseminated intravascular coagulation, whatever anticoagulation protocol is used. Low-dose heparin continuously administered is considered.

Between April 1976 and December 1984, 297 patients underwent major elective and emergency surgery using intraoperative autotransfusion (Bentley ATS unit). An amount of 732 l of blood was reinfused, representing 61% of the total intraoperative blood transfusion. Thanks to this method, an average 2.46 l of blood per patient was spared, with a range of 0.9 to 6 l according to the type of surgery (elective or emergency). Twelve accidents are reported, including four bradycardias (less than 45 b X min-1), two air emboli and six haemorrhages due to an excess of anticoagulation. These complications were related either to poor technique (too great a transfusion output) or insufficient blood anticoagulation control. Simplicity of use and high transfusion output of the device adapted to the blood loss are the advantages of intraoperative autotransfusion.

Many factors already contribute to limit the amount of bank blood available for therapeutic use; a possible reduction in the amount of available blood could stem from the relative indifference of young people towards the gift of blood and the increase in the size of the pool of positive carriers of Australian antigen. Moreover, new operations appear (coronary by-pass) which increase the demand for blood. It is imperative that we adopt attitudes and practice techniques that will contribute to the conservation of blood. This paper discusses the advantages of an active blood bank committee which, alone, can reduce the consumption of blood by 20 percent. Moreover, actual techniques for conservation of blood are reviewed: controlled hypotension, haemodilution and intraoperative blood salvage.

From their experiences on animals and from its surgical applications the authors can say that the procedure of autotransfusion in vascular operations is worthwhile and safe. Elements of blood auto transfused are a little or not at all altered. Autotransfusion reduces requiremnts of bank blood, rare and containing risks.