Are Routine Blood Salvage/Preservation Measures Justified in All Patients Undergoing Primary TKA and THA?

Perioperative Allogeneic Red Blood-Cell Transfusion Associated with Surgical Site Infection After Total Hip and Knee Arthroplasty

BACKGROUND

Perioperative allogeneic red blood-cell transfusion is a suspected risk factor for surgical site infection (SSI) after total joint arthroplasty (TJA), but the interrelationships among SSI risk, transfusion dose, preoperative anemia, and the presence of coagulopathies have not been well described.

METHODS

Data on SSI within 1 year after surgery as well as on transfusion with blood products within 30 days after surgery were obtained for 6,788 patients who had undergone primary or revision total hip or knee arthroplasty from 2000 to 2011 in a single hospital system. Multivariate logistic regression modeling was used to determine the independent association between allogeneic red blood-cell transfusion and SSI.

RESULTS

There was a dose-dependent association between allogeneic red blood-cell transfusion and SSI, with the infection rate increasing as the transfusion dose increased from 1 unit (odds ratio [OR] = 1.97; 95% confidence interval [CI] = 1.38, 2.79; p < 0.001), to 2 units (OR = 2.20; CI = 1.37, 3.44; p = 0.002), to 3 units (OR = 3.66; CI = 1.72, 7.16; p = 0.001), and to >3 units (OR = 7.40; CI = 4.91, 11.03; p < 0.001) after controlling for medical comorbidities, planned procedure, preoperative anemia, and preexisting coagulopathies. A preexisting bleeding disorder (OR = 2.09; CI = 1.57, 2.80; p < 0.001) and clotting disorder (OR = 1.37; CI = 1.14, 1.64; p = 0.001) and preoperative anemia (OR = 3.90; CI = 3.31, 4.61; p < 0.001) were all independent risk factors for transfusion after adjusting for the planned procedure.

CONCLUSIONS

We found a dose-dependent relationship between allogeneic red blood-cell transfusion and SSI risk after total hip or knee arthroplasty. Additionally, preoperative anemia or a known bleeding or clotting disorder were risk factors for the need for allogeneic red blood-cell transfusion. Our findings underscore the need for preoperative risk assessment, methods to limit surgical tissue injury, and optimized blood conservation strategies.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative autotransfusion drain after total hip arthroplasty: a meta-analysis of randomized controlled trials

The use of a postoperative autotransfusion drain (PATD) to reduce allogenic blood transfusions in total hip arthroplasty (THA) remains controversial. Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of this technique. Randomized controlled trials (RCTs) were identified from PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Thirteen RCTs (1,424 participants) were included in our meta-analysis. The results showed that PATD reduced the rate of allogenic transfusions (RR = 0.56; 95% CI [0.40, 0.77]) and total blood loss (MD = -196.04; 95% CI [-311.01, -81.07]). Haemoglobin (Hb) levels were higher in the PATD group on postoperative day 1 (MD = 0.28; 95% CI [0.06, 0.49]), but no significant differences on postoperative days 2 or 3 (MD = 0.29; 95% CI [-0.02, 0.60]; MD = 0.26; 95% CI [-0.04, 0.56]; respectively). There were no differences in length of hospital stay (MD = -0.18; 95% CI [-0.61, 0.25]), febrile reaction (RR = 1.26; 95% CI [0.95, 1.67]), infection (RR = 0.95; 95% CI [0.54, 1.65]), wound problems (RR = 1.07; 95% CI [0.87, 1.33]), or serious adverse events (RR = 0.59; 95% CI [0.10, 3.58]). Our findings suggest that PATD is effective in reducing the rate of allogenic transfusion. However, the included studies are inadequately powered to conclusively determine the safety of this technique.