Erythropoietin and preoperative autologous blood donation in the prevention of hepatitis C infection: necessity or luxury?

The Use of Preoperative Epoetin-α in Revision Hip Arthroplasty

Purpose:

To evaluate the efficacy of preoperative epoetin-α on the revision hip arthroplasty patient. We hypothesized that epoetin-α will reduce blood transfusion. A pertinent review of the literature is provided.

Methods:

Forty-six patients were retrospectively reviewed. Sixteen patients received epoetin-α. Patients were case matched by age, preoperative hemoglobin, surgery, gender, and BMI. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used.

Results:

Blood transfusion and length of stay were decreased in the epoetin-α group. Hemoglobin in the intervention group increased from 12.0 to 14.5, preoperatively. Patients who received epoetin-α were 0.78 (RR=0.225) times as likely to receive a transfusion. Number Needed to Treat (NNT) to avoid one allogeneic transfusion was 1.84. Age, Gender, BMI, ASA, total and hidden blood loss, preoperative Iron supplements, preop Hct, preop PLT, PT, PTT, and INR were similar. One (6.0%) patient developed an uncomplicated deep venous thrombosis in the intervention group.

Conclusions:

The mildly anemic revision hip arthroplasty patient is at increased risk for transfusion. Epoetin-α increased preoperative hemoglobin counts and reduced transfusions in this study; it also decreased patient length of hospital stay likely allowing for an earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted.

Tranexamic acid reduces allogenic transfusion in revision hip arthroplasty

BACKGROUND

Revision THA is associated with high blood loss and a high probability of blood transfusion in the perioperative period. In November 2003, government legislation established the Blood Utilization Program at our center to reduce the rate and risks associated with allogenic transfusion.

QUESTIONS/PURPOSES

The purposes of this study were to (1) determine whether the allogenic transfusion rate in patients undergoing revision THA decreased in those who were reviewed preoperatively by the Blood Utilization Program versus those who were not; (2) determine whether tranexamic acid reduced the rate of transfusion; and (3) identify potential perioperative clinical parameters that are associated with an increased risk of blood transfusion.

METHODS

We included all 159 patients who underwent revision THA from January 2006 to October 2008 having either a socket and/or femoral stem revision except those having only a liner exchange. One hundred and one patients attended the Blood Utilization Program preoperatively and 58 patients did not (ie, they required urgent/emergency surgery).

RESULTS

The Blood Utilization Program referral made no difference in transfusion rate or transfusion amount; however, the transfusion rates and amount were decreased by 8% and one unit, respectively. In patients referred to the Blood Utilization Program, the intraoperative use of tranexamic acid (an antifibrinolytic) was associated with reduced transfusions, regardless of dosage; preoperative erythropoietin tended to reduce transfusions while preoperative oral iron supplements did not.

CONCLUSIONS

To further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

Implications of revision total elbow arthroplasty on blood transfusion

HYPOTHESIS

We hypothesize that there is a greater rate of blood transfusions following revision total elbow arthroplasty (TEA) as compared with primary TEA, with lower preoperative hemoglobins and longer operative times being significant risk factors.

MATERIALS AND METHODS

The results of 193 operations (172 patients) between January 2000 and December 2004 were retrospectively reviewed. Excluded were patients with primary impairment of platelet or coagulation function or with chronic liver impairment. Univariate and chi(2) analyses were used to determine which risk factors were predictive of transfusion.

RESULTS

The transfusion rate was 7.8% for revision arthroplasties and 1.0% after primary procedures (P < .02). Revision surgery (P < .02), longer operative times (P < .01), longer anesthesia times (P < .01), lower preoperative hemoglobin level (10.6+/-0.5 g/dL; P < .01), and lower body mass index (P=.04) significantly increased the risk of blood transfusion.

DISCUSSION

The need for blood transfusion after revision elbow arthroplasty is statistically greater than that after primary procedures. Furthermore, revision surgery, increased operative and anesthesia times, lower preoperative hemoglobin level, and decreased body mass index increase the risk of requiring a transfusion. Patients undergoing revision surgeries with preoperative hemoglobin levels of less than 10 g/dL are especially at risk of transfusion, and the proper precautions should be enacted during the perioperative period.

Autologous Blood Transfusion in TRAM Breast Reconstruction:

Many centers continue to use preoperative donation of autologous blood as part of their reconstructive protocol for pedicled transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction, despite the lack of support for this in the English language literature. This prospective study compares 3 groups of patients undergoing reconstruction with TRAM flaps using 3 different protocols in 3 different centers. Group 1 did not donate blood preoperatively. Group 2 donated 1 to 2 U preoperatively and received their blood intraoperatively or during the early postoperative period. Group 3 did not receive their autologous blood unless they displayed symptoms of hypovolemia or anemia postoperatively. There were no statistical differences between groups in age, length of stay, or number of unilateral versus bilateral procedures. Patients who did not donate autologous blood (group 1) had statistically significantly higher preoperative and postoperative day 3 hemoglobin levels than patients in the groups that did predonate. The authors conclude that preoperative autologous donation of blood does not confer any clinical advantage to patients undergoing autologous breast reconstruction using pedicled TRAM flaps.

Clinical factors associated with an increased risk of perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty

BACKGROUND

The aim of this study was to identify clinical factors associated with an increased need for perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty.

METHODS

We evaluated eighty-five consecutive nonanemic patients who underwent elective, unilateral, cementless, primary total hip arthroplasty and met our inclusion criteria. We attempted to determine whether clinical parameters influencing perioperative blood loss, such as age, gender, hypertension, and body mass index, were also associated with the need for perioperative blood transfusion.

RESULTS

Perioperative blood transfusion was required in twenty-four (28%) of the eighty-five nonanemic patients. When considered alone, age, gender, hypertension, and body mass index were not significantly associated with an increased risk of perioperative blood transfusion, on the basis of the numbers available. In contrast, there was a significantly increased risk of blood transfusion when two or more of these clinical parameters were present (p = 0.02).

CONCLUSIONS

Our findings indicate that clinical variables such as age, gender, hypertension, and body mass index may have a synergistic effect on the risk of transfusion in patients undergoing elective total hip arthroplasty. The simultaneous analysis of these parameters might help to stratify patients with different risks for transfusion and may increase the efficiency and reduce the cost of blood-ordering practices associated with total hip arthroplasty.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors

BACKGROUND

Several studies have established a relationship between the preoperative hemoglobin level and the need for postoperative blood transfusion. We analyzed the relationship between preoperative hemoglobin levels, as well as other factors such as age, gender, weight, height, type and duration of the total joint replacement surgery, and the need for postoperative blood transfusion.

METHODS

A retrospective study of 296 patients treated with 370 procedures (209 total hip arthroplasties [56.5%] and 161 total knee arthroplasties [43.5%]) from 1994 to 1998 was carried out. A univariate analysis was performed to establish the relationship between all independent variables and the need for postoperative transfusion. Variables that were determined to have a significant relationship were included in a multivariate analysis.

RESULTS

The univariate analysis revealed a significant relationship between the need for postoperative blood transfusion and preoperative hemoglobin levels (p = 0.0001), duration of surgery (p = 0.0001), weight (p = 0.002), height (p = 0.019), and gender (p = 0.0056). However, the multivariate analysis identified a significant relationship only between the need for transfusion and the preoperative hemoglobin level (p = 0.0001) and weight (p = 0.011); height (p = 0.776) and gender (p = 0.122) were discounted as significant factors. Patients with a preoperative hemoglobin level of <130 g/L had a four times greater risk of having a transfusion than did those with a hemoglobin level between 130 and 150 g/L and a 15.3 times greater risk than did those with a hemoglobin level of >150 g/L.

CONCLUSIONS

The preoperative hemoglobin level (p = 0.0001) and weight of the patient (p = 0.011) were shown to predict the need for blood transfusion after hip and knee replacement.