Review of transfusion practice in orthopaedic surgery

Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes

Despite attempts to minimize exposure to allogeneic blood, there are little data on recent nationwide trends in transfusion following total hip arthroplasty (THA) and no consensus on indications. The purpose of this study was to examine the rate, predictors, and inpatient outcomes associated with transfusion after primary THA. This retrospective cohort study analyzed the data collected from US Nationwide Inpatient Sample (NIS) for each year during the period 2005-2008 to assess the trends in transfusion in patients who underwent elective primary THA. Logistic regression models were used to evaluate the predictive risk factors for blood transfusion. The University Hospital Consortium (UHC) database was also queried to examine the variability in rates of transfusion at different academic medical centers. A total of 129,901 patients were identified in the NIS database. The transfusion rates following THA consistently increased from 18.12% in 2005 to 21.21% in 2008 (P<0.0001). Hospitals in the Northeast and Midwest region had the highest and lowest rates of transfusion, respectively. Significant risk factors for blood transfusion were female gender (odds ratio, OR 2.1), age above 85 (OR 2.9), African-American race (OR 1.7), Medicare payor status (OR 1.6), being at a hospital in the Northeast Region (OR 1.4), the presence of preoperative anemia (OR 1.6), having at least one comorbidity (OR 1.3), and a high Charlson Index score (OR 2.2). Patients receiving blood transfusions had increased in-hospital mortality, longer lengths of stay, and higher total charges compared to non-transfused patients (P<0.001). The UHC database demonstrated that transfusion rates vary widely across different institutions from <5% to >80%. The incidence of blood transfusion has recently increased following total hip arthroplasty and there is great variability in practice. We identified several patient risk factors along with the morbidity and mortality independently associated with transfusion following THA. Further work is needed to standardize the approach to blood conservation and minimize exposure to allogenic blood.

National comparative audit of blood use in elective primary unilateral total hip replacement surgery in the UK

INTRODUCTION

Blood is a scarce and expensive product. Although it may be life-saving, in recent years there has been an increased emphasis on the potential hazards of transfusion as well as evidence supporting the use of lower transfusion thresholds. Orthopaedic surgery accounts for some 10% of transfused red blood cells and evidence suggests that there is considerable variation in transfusion practice.

PATIENTS AND METHODS

NHS Blood and Transplant, in collaboration with the Royal College of Physicians, undertook a national audit on transfusion practice. Each hospital was asked to provide information relating to 40 consecutive patients undergoing elective, primary unilateral total hip replacement surgery. The results were compared to indicators and standards.

RESULTS

Information was analysed relating to 7465 operations performed in 223 hospitals. Almost all hospitals had a system for referring abnormal pre-operative blood results to a doctor and 73% performed a group-and-save rather than a cross-match before surgery. Of hospitals, 47% had a transfusion policy. In 73%, the policy recommended a transfusion threshold at a haemoglobin concentration of 8 g/dl or less. There was a wide variation in transfusion rate among hospitals. Of patients, 15% had a haemoglobin concentration less than 12 g/dl recorded in the 28 days before surgery and 57% of these patients were transfused compared to 20% with higher pre-operative values. Of those who were transfused, 7% were given a single unit and 67% two units. Of patients transfused two or more units during days 1-14 after surgery, 65% had a post transfusion haemoglobin concentration of 10 g/dl or more.

CONCLUSIONS

Pre-operative anaemia, lack of availability of transfusion protocols and use of different thresholds for transfusion may have contributed to the wide variation in transfusion rate. Effective measures to identify and correct pre-operative anaemia may decrease the need for transfusion. A consistent, evidence-based, transfusion threshold should be used and transfusion of more than one unit should only be given if essential to maintain haemoglobin concentrations above this threshold.

Management of blood loss in periacetabular osteotomy

The aim of this study was to determine the efficacy and cost-effectiveness of the use of predonation of autologous blood for the periacetabular osteotomy. We carried out a retrospective single surgeon series study looking at patient demographics, intraoperative blood loss, volume of red cells returned (by cell salvage and allogenic/autologous transfusion), and comparing pre- and postoperative haemoglobin levels in those that predonated and those that did not. One hundred and twenty-two procedures were performed on 107 patients between 1996 and 2005. An initial audit (22 procedures) revealed high wastage (45% returned) of allogenic blood. A predonation protocol was initiated and subsequently 100 procedures in 91 patients were performed. In 82 procedures, the patients were eligible for predonation. A total of 226 units of autologous blood were predonated and 92% was used. Only 13 of these patients (16%) required additional allogenic transfusion for unforeseen excessive blood loss intraoperatively. A set protocol for predonation reduces the need for allogenic transfusion and involves minimal wastage. In a procedure which has significant blood loss, we suggest that preoperative autologous donation is a safe and cost effective method of managing blood loss.