Efficacy of intraoperative autotransfusion in primary total hip arthroplasty

Effectiveness of Fibrin Sealant after Cementless Total HIP Replacement: A Double-Blind Randomized Controlled Trial

Fibrinogen-based sealants have been used to improve hemostasis after total hip replacement (THR) with conflicting results. We therefore conducted a double-blind randomized controlled trial to determine whether the commercially available fibrin sealant Quixil is effective in reducing the volume of red blood cell transfusions, postoperative blood loss and postoperative hemoglobin drop. Patients with coxarthrosis scheduled for primary cementless THR, were enrolled in a single hospital setting and randomized to either a fibrin sealant group (n=35) or a negative control group (n=35). The surgeon was blind to group allocation until the moment of fibrin application, while the cardiologist determining the need for transfusions remained blind throughout the intervention. In the fibrin sealant group, less blood was lost in the first 48 hours (median, 125 vs 200 ml), fewer patients required allogeneic blood transfusion (1 vs 6 in the control group), and fewer total units of allogeneic blood were transfused (2 vs 12). These differences, however, were not significant partly due to confounding from the use of autologous transfusion of predeposited blood (according to a more liberal regime) and intraoperative autologous blood reinfusion in some patients of both groups. Excluding these last individuals from analysis, no remaining patient of the fibrin sealant group had an allogeneic blood transfusion that, instead, was carried out on 5 patients (23.8%) of the control group (p=0.048). Overall postoperative hemoglobin drop from baseline was significantly less in the fibrin-treated group on day 7 (mean, 3.5 vs 4.5 g/dl; p=0.02). No adverse events were associated with fibrin treatment. These results strengthen the evidence in support of the safety and efficacy of the use of fibrin sealant in improving hemostasis after THR. Clinical trial registration: EudraCT 2008-002024-28.

Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty

PURPOSE

To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood.

METHODS

We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 g.L(-1) were given erythropoietin, dosed by weight. Subjects with Hb 130-139 g.L(-1) underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb >139 g.L(-1) received no special intervention, unless they were aged >70 yr and weighed < 70 kg, in which case they received oral iron and folate supplementation.

RESULTS

The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group.

CONCLUSION

A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.

Predicting transfusion in shoulder arthroplasty

BACKGROUND

This study was conducted to evaluate the incidence of transfusion in shoulder arthroplasty, determine clinical factors associated with increased risk for transfusion, and develop an algorithm to assist the surgeon in preoperative planning with regards to blood management.

MATERIAL AND METHODS

The study had 2 phases: (1) development of a clinical prediction rule for transfusion using 280 procedures and (2) a validation study of the algorithm applied to 109 new patients. Phase 1 consisted of a retrospective record review of 280 consecutive shoulder arthroplasties to determine risk factors for transfusion. Phase 1 also identified a preoperative hemoglobin level of less than 12.5 g/dL as predictive of the need for blood transfusion. This cutoff was prospectively applied to 109 patients undergoing shoulder arthroplasty in phase 2.

RESULTS

The transfusion rate for phase 1 was 19.6%. Preoperative hemoglobin level (P < .001), age (P= .003), and the number of comorbid conditions (P = .005) were statistically significant risk factors. Patients with a preoperative hemoglobin level of less than 12.5 g/dL have a 4-fold increased risk of requiring a blood transfusion. In phase 2, the cutoff of less than 12.5 g/dL yielded a sensitivity of 88%, specificity of 78%, and positive and negative likelihood ratios of 4.0 and 0.15, respectively.

CONCLUSION

Preoperative hemoglobin level, age, and number of comorbid conditions are all predictive of transfusion in shoulder arthroplasty. Tailoring blood ordering based on a preoperative hemoglobin level of 12.5 g/dL is safe and effective.

LEVEL OF EVIDENCE

Prognostic study, level 2.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Intraoperative blood management in joint replacement surgery

Interest is growing in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery, especially in the field of joint replacement. Several methods have proven successful in reducing intraoperative blood loss, which can translate into lessened allogeneic and autologous transfusion requirements. Available techniques include acute normovolemic hemodilution, hypotensive anesthesia, intraoperative blood salvage, specialized cautery, topical hemostatic agents, and pharmacologic agents given in the perioperative period. The greatest potential benefit arises in operations with greater expected blood loss or in special situations such as in patients with religious issues, bilateral joint replacement, coagulation disorders, or significant preoperative anemia.

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

BACKGROUND

The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.

METHODS

In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (mililitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.

RESULTS

Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r2 = 0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0-4 u). However, 32% of such patients required allogeneic blood.

CONCLUSIONS

Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.

Efficacy and cost considerations of intraoperative autologous transfusion in spinal fusion for idiopathic scoliosis with predeposited blood

STUDY DESIGN

One hundred five patients with adolescent idiopathic scoliosis who underwent posterior spinal instrumentation and fusion with predeposited autologous blood, with or without intraoperative autologous transfusion, were reviewed.

OBJECTIVE

To determine the benefit/nonbenefit of intraoperative autologous transfusion in diminishing the need for homologous blood and influencing post-operative hematocrit values in healthy adolescents undergoing spinal fusion for scoliosis.

SUMMARY OF BACKGROUND DATA

A steady increase in the use of intraoperative autologous transfusion in recent years has occurred without guidelines regarding which procedures and patient populations would be best served. Previous studies have failed to determine the cost effectiveness and actual reduction in homologous blood exposure attributable to intraoperative autologous transfusion in adolescents who have undergone preoperative phlebotomy.

METHODS

Fifty-five adolescents (intraoperative autologous transfusion group) who underwent posterior instrumentation and fusion for idiopathic scoliosis with the use of an intraoperative autologous transfusion device were compared to 50 patients (control group) who underwent the same procedure without the intraoperative autologous transfusion device.

RESULTS

The average percent salvage of red blood cells by the intraoperative autologous transfusion device was 35%. The control group utilized significantly more of the predonated autologous blood than the intraoperative autologous transfusion group (1.34 units/case vs. 1.78 units/case, P < 0.05). Homologous blood usage was the same in both groups. Two patients in the intraoperative autologous transfusion group required nondirected homologous blood (total of four units), compared to three patients in the control group (total of four units) (P = 0.048). Using multiple regression analysis, the total number of transfusions was significantly correlated with the estimated blood loss and the duration of surgery in both groups. Postoperative hematocrit levels were slightly higher in the control group, but there was not a significant difference.

CONCLUSIONS

The addition of intraoperative autologous transfusion to a preoperative phlebotomy program had no benefit on homologous blood exposure or post-operative hematocrit changes in this population. Blood requirements for this procedure can be met less expensively and more reliably by merely donating one's own blood.

The role of autologous blood transfusion in joint replacement surgery

The efficacy of predeposited autologous blood transfusion (PABT) with and without intra/postoperative blood salvage to reduce or eliminate the need for homologous blood transfusion (HBT) in primary total hip or knee replacement surgery was investigated by retrospective and prospective studies. Depending on the type of surgery, one to three units of PABT eliminated the need for HBT in 50 to 78% of patients, but, intra/postoperative blood salvage alone reduced the need only in 11 to 29%. In contrast, blood salvage, when combined with three units of PABT, eliminated the need for HBT in all patients undergoing primary joint replacement surgery. A cost comparison analysis showed that blood salvage was more expensive than PABT, and therefore it should be limited to patients who had predeposited fewer than three units of autologous blood.

The hemostatic effects of desmopressin on patients who had total joint arthroplasty. A double-blind randomized trial

The effects of desmopressin on postoperative bleeding and postoperative transfusion requirements were studied in ninety-two hemostatically normal patients who had had an elective primary total hip or total knee arthroplasty. The patients were randomized into either a placebo or a desmopressin group in a double-blind prospective clinical trial. During closure of the wound, desmopressin (0.03 microgram per kilogram of body mass) or the placebo was infused into a peripheral vein over a twenty-minute period. Compared with the placebo, desmopressin did not significantly decrease blood loss or transfusion requirements, and it did not affect the postoperative platelet or fibrinogen levels or the bleeding time. The results were no different even when the treatment and control groups were matched according to surgeon, use of cement for the femoral and knee components, preoperative use of non-steroidal anti-inflammatory agents, or performance of a lateral release for total knee arthroplasty. We concluded that desmopressin does not reduce blood loss or transfusion requirements after total joint arthroplasty.

Reinfusion of postoperative wound drainage in total joint arthroplasty. Red blood cell survival and coagulopathy risk

Fifty patients with total joint arthroplasties (28 total hip arthroplasties, 11 total knee arthroplasties, and 11 bilateral total knee arthroplasties) received autotransfusions from their postoperative wound drainage. The blood was collected in a closed sterile drainage system without any additional anticoagulant. Pre- and postoperative measurements were made of the patient's hemoglobin, platelets, fibrinogen, haptoglobin, fibrin degradation products, and D-dimer (a specific type of fibrin degradation product). Red blood cell survival was assessed in 16 of the patients by labeling the shed blood with 51Cr sodium chromate prior to reinfusion. To control for fluid shifts, continued bleeding, and dilution effects of further transfusions in the immediate postoperative period, 10 patients also had their native blood labeled with 111In oxime. In this study, the mean estimated blood loss was 1,062 mL (+/- 1,247) with a mean wound drainage of 836 mL (+/- 338). Of this, a mean of 450 mL (+/- 261) of blood was was given back to the patient in addition to routine, preoperative autologous donated blood. Six (12%) patients experienced transient fevers at the time of retransfusion. Detailed hematologic studies were performed on the shed blood in 19 patients. The collected blood was completely defibrinated, but did contain fibrin degradation products, as indicated by the D-dimer level, and hemolyzed blood as the haptoglobin was reduced. Even though the blood containing the above breakdown products was reinfused to the patients, there were no clinical manifestations of disseminated intravascular coagulation. Both the hemolyzed and defibrinated products were subsequently cleared by the body.(ABSTRACT TRUNCATED AT 250 WORDS)