Autologous blood transfusion in total knee replacement surgery

Updated Clinical Review: Perioperative Use of Tranexamic Acid in Orthopedics and Other Surgeries

Tranexamic acid is a well-known antifibrinolytic that has numerous clinical indications, and it is efficacious and safe in many perioperative scenarios including patients with some thrombotic risks. However, further studies that characterize clinical outcomes concerning dosing, timing, and routes in combination are needed in ultra high-risk populations.

Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery

BACKGROUND

Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient.

OBJECTIVES

To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status.

SELECTION CRITERIA

We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke.

AUTHORS' CONCLUSIONS

In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.

Is a Patient Blood Management programme economically reasonable?

PURPOSE OF REVIEW

The value of healthcare is defined as the achieved health outcome in relation to the incurred costs. Patient Blood Management (PBM) is a multidisciplinary, evidence-based and patient-centred concept to optimize the patients' red blood cell mass, minimize blood loss and bleeding and to secure the physiological reserve, including the promotion of evidence-based transfusion strategies. This review describes the healthcare value and the cost effectiveness of single PBM measures as well as the implementation of comprehensive PBM programmes.

RECENT FINDINGS

Overall, measures improving surgical outcome and reducing hospital length of stay, such as intravenous iron supplementation in iron deficient anaemic patients, the use of antifibrinolytic agents for the treatment of bleeding, the use of cell salvage and adherence to an evidence-based transfusion strategy, are associated with cost savings.

SUMMARY

Although several single PBM measures have been shown to be effective and cost-efficient, it remains challenging to compare the results among differing healthcare systems.

Hemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review

PURPOSE

To investigate the efficacy of non-tranexamic acid (TXA) on reducing blood loss and requirements of allogeneic blood transfusion (ABT) in total knee arthroplasty (TKA).

METHODS

The PubMed, EMBASE, and the Cochrane Library databases were researched since incipiency to June 2018. Only randomized controlled trials (RCTs) involved with non-TXA hemostatic techniques in TKA met the inclusion criteria.

RESULTS

A total of 36 RCTs, including 1511 patients, were recruited for analysis. The results of subgroup analysis revealed that hemostatic techniques, which could substantially decrease the rate of ABT, were cell salvage with the transfusion trigger of 9 mg/dl, fibrin sealant with a dosage of 10 ml, and postoperative flexion position.

CONCLUSION

The available evidence in this meta-analysis suggests that postoperative flexion position, fibrin sealant, and cell salvage can substantially decrease the rate of ABT in TKA. Further studies, including more hemostatic methods and high-quality research, are expected.

Postoperative shed autologous blood reinfusion does not decrease the need for allogeneic blood transfusion in unilateral and bilateral total knee arthroplasty

Postoperative shed autologous blood reinfusion techniques have been used for decades in total knee arthroplasty (TKA), but the effectiveness of this procedure is still a matter of debate. This multicenter retrospective study investigated the medical records of patients who underwent unilateral and bilateral TKA from January 1, 2015 to December 31, 2017 in three hospitals. According to whether postoperative shed autologous blood reinfusion was used, the patients were divided into the control group and the shed autologous blood reinfusion group. The volume of perioperative infusion of red blood cells and plasma, the blood transfusion-related costs, and the postoperative hospital stay were compared between the two groups of patients. A total of 200 unilateral and 74 bilateral TKA were included after successful matching. Among the patients who underwent unilateral TKA, the control group and the shed autologous blood reinfusion group had 95 and 91 patients, respectively, who received allogeneic blood infusion (P = 0.268). There was no significant difference in the number of units of allogeneic red blood cells infused (P = 0.154), while the transfusion-related cost was increased (P<0.001). The same phenomena were observed over the patients underwent bilateral TKA. Shed autologous blood reinfusion does not reduce the need for infusing allogeneic red blood cells. In addition, the procedure increases patient expense and may also lead to an extended postoperative hospital stay.

Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence

Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.

Application of postoperative autotransfusion in total joint arthroplasty reduces allogeneic blood requirements: a meta-analysis of randomized controlled trials

Background

Total joint arthroplasty is associated with significant blood loss and often requires blood transfusion. However, allogeneic blood transfusion (ABT) may lead to severe problems, such as immunoreaction and infection. Postoperative autotransfusion, an alternative to ABT, is controversial. We conducted a meta-analysis to evaluate the ability of postoperative autotransfusion to reduce the need for ABT following total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

Systematic literature searches for randomized controlled trials were performed using PubMed, Embase, and the Cochrane Library until February 2016. Relative risks (RRs) and weighted mean differences with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect models; we also evaluated publication bias and heterogeneity.

Results

Seventeen trials with a total of 2314 patients were included in the meta-analysis. The pooled RRs of ABT rate between autotransfusion and the regular drainage/no drainage groups for TKA and THA were 0.446 (95% CI = 0.287, 0.693; p < 0.001) and 0.757 (95% CI = 0.599, 0.958; p = 0.020), respectively. In the subgroup analysis performed in TKA patients according to control interventions, the pooled RRs were 0.377 (95% CI = 0.224, 0.634; p < 0.001) (compared with regular drainage) and 0.804 (95% CI = 0.453, 1.426, p = 0.456) (compared with no drainage). In the subgroup analysis performed for THA, the pooled RRs were 0.536 (95% CI = 0.379, 0.757, p < 0.001) (compared with regular drainage) and 1.020 (95% CI = 0.740, 1.405, p = 0.904) (compared with no drainage).

Conclusions

Compared to regular drainage, autotransfusion reduces the need for ABT following TKA and THA. This reduction is not present when comparing autotransfusion to no drainage. However, the reliability of the meta-analytic results concerning TKA was limited by significant heterogeneity in methods among the included studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1710-2) contains supplementary material, which is available to authorized users.

Do autologous blood transfusion systems reduce allogeneic blood transfusion in total knee arthroplasty?

PURPOSE

To study whether autologus blood transfusion systems reduce the requirement of allogneic blood transfusion in patients undergoing total knee arthroplasty.

METHODS

A comprehensive search of the published literature with PubMed, Scopus and Science direct database was performed. The following search terms were used: (total knee replacement) OR (total knee arthroplasty) OR (TKA) AND (blood transfusion) OR (autologous transfusion) OR (autologous transfusion system). Using search syntax, a total of 748 search results were obtained (79 from PubMed, 586 from Science direct and 83 from Scopus). Twenty-one randomized control trials were included for this meta-analysis.

RESULTS

The allogenic transfusion rate in autologus blood transfusion (study) group was significantly lower than the control group (28.4 and 53.5 %, respectively) (p value 0.0001, Relative risk: 0.5). The median units of allogenic blood transfused in study control group and control group were 0.1 (0.1-3.0) and 1.3 (0.3-2.6), respectively. The median hospital stay in study group was 9 (6.7-15.6) days and control group was 8.7 (6.6-16.7) days. The median cost incurred for blood transfusion per patient in study and control groups was 175 (85.7-260) and 254.7 (235-300) euros, respectively.

CONCLUSION

This meta-analysis demonstrates that the use of auto-transfusion systems is a cost-effective method to reduce the need for and quantity of allogenic transfusion in elective total knee arthroplasty.

LEVEL OF EVIDENCE

Level I.

The efficacy and safety of autologous blood transfusion drainage in patients undergoing total knee arthroplasty: a meta-analysis of 16 randomized controlled trials

Background

Autologous blood transfusion drainage (ABTD) has been used for many years to reduce blood loss in total knee arthroplasty (TKA). We evaluate the current evidence concerning the efficiency and safety of ABTD used in TKA compared with conventional suction drainage (CSD).

Methods

We performed a systematic literature search of the PubMed, Embase, Cochrane Library and four Chinese databases. All randomized controlled trials (RCTs) that compared the effects of ABTD versus CSD in TKA were included in the meta-analysis.

Results

Sixteen RCTs involving 1534 patients who compared the effects of ABTD versus CSD were included. Five of the RCTs were performed in Asia, ten in Europe, and one in North America. Patients in the ABTD group had a lower blood transfusion rate (OR: 0.25 [0.13, 0.47]; Z = 4.27, P < 0.0001) and fewer units transfused per patient (WMD: −0.68 [−0.98, −0.39]; Z = 4. 52, P < 0.00001) than did patients in the CSD group. Wound complications, deep vein thrombosis, febrile complications, post-operative hemoglobin days 5–8, drainage volume, and length of hospital stay did not differ significantly between the two types of drainage systems.

Conclusion

This meta-analysis suggests that ABTD is a safe and effective method that yields a lower blood transfusion rate and fewer units transfused per patient in TKA compared with CSD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1301-7) contains supplementary material, which is available to authorized users.

Navigated vs Conventional Total Knee Arthroplasty: Is There a Difference in the Rate of Respiratory Complications and Transfusions?

BACKGROUND

Proponents of navigation in total knee arthroplasty (TKA) report lower rates of systemic embolization and perioperative bleeding compared to conventional TKA given that breeching the intramedullary canal is not required.

METHODS

We queried the National Surgical Quality Improvement Program to compare perioperative respiratory complications and transfusions between navigated and conventional TKA. We identified 2008 patients who underwent navigated TKA. These patients were matched 4:1 to a control group of 8026 patients.

RESULTS

Conventional TKA resulted in similar odds of having a respiratory complication compared to navigated TKA (odds ratio = 1.35, P = .44). However, conventional TKA was found to be an independent predictor for requiring a transfusion perioperatively (odds ratio = 1.90, P < .001).

CONCLUSION

Use of navigation in TKA results in less perioperative transfusions but has no influence on the rate of respiratory complications.

Blood Management Strategies in Total Knee Arthroplasty

A perioperative blood management program is one of a number of important elements for successful patient care in total knee arthroplasty (TKA) and surgeons should be proactive in its application. The aims of blood conservation are to reduce the risk of blood transfusion whilst at the same time maximizing hemoglobin (Hb) in the postoperative period, leading to a positive effect on outcome and cost. An individualized strategy based on patient specific risk factors, anticipated blood loss and comorbidities are useful in achieving this aim. Multiple blood conservation strategies are available in the preoperative, intraoperative and postoperative periods and can be employed in various combinations. Recent literature has highlighted the importance of preoperative Hb optimization, minimizing blood loss and evidence-based transfusion guidelines. Given TKA is an elective procedure, a zero allogenic blood transfusion rate should be the aim and an achievable goal.

Comparison between autologous blood transfusion drainage and closed-suction drainage/no drainage in total knee arthroplasty: a meta-analysis

Background

Autologous blood transfusion (ABT) drainage system is a new unwashed salvaged blood retransfusion system for total knee replacement (TKA). However, whether to use ABT drainage, closed-suction (CS) drainage or no drainage in TKA surgery remains controversial. This is the first meta-analysis to assess the clinical efficiency, safety and potential advantages regarding the use of ABT drains compared with closed-suction/no drainage.

Methods

PubMed, Embase, and the Cochrane Library were comprehensively searched in March 2015. Fifteen randomized controlled trials (RCTs) were identified and pooled for statistical analysis. The primary outcome evaluated was homologous blood transfusion rate. The secondary outcomes were post-operative haemoglobin on days 3–5, length of hospital stay and wound infections after TKA surgery.

Results

The pooled data included 1,721 patients and showed that patients in the ABT drainage group might benefit from lower blood transfusion rates (16.59 % and 37.47 %, OR: 0.28 [0.14, 0.55]; 13.05 % and 16.91 %, OR: 0.73 [0.47,1.13], respectively). Autologous blood transfusion drainage and closed-suction drainage/no drainage have similar clinical efficacy and safety with regard to post-operative haemoglobin on days 3–5, length of hospital stay and wound infections.

Conclusions

Autologous blood transfusion drainage offers a safe and efficient alternative to CS/no drainage with a lower blood transfusion rate. Future large-volume high-quality RCTs with extensive follow-up will affirm and update this system review.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0993-z) contains supplementary material, which is available to authorized users.

Washed cell salvage in surgical patients: A review and meta-analysis of prospective randomized trials under PRISMA

BACKGROUND

Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage.

METHODS

We performed a meta-analysis of randomized controlled trials in which patients, scheduled for all types of surgery, were randomized to washed cell salvage or to a control group with no cell salvage. Data were independently extracted, risk ratio (RR), and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary endpoint was the number of patients exposed to allogeneic red blood cell (RBC) transfusion.

RESULTS

Out of 1140 search results, a total of 47 trials were included. Overall, the use of washed cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 39% (RR = 0.61; 95% CI 0.57 to 0.65; P < 0.001), resulting in an average saving of 0.20 units of allogeneic RBC per patient (weighted mean differences [WMD] = -0.20; 95% CI -0.22 to -0.18; P < 0.001), reduced risk of infection by 28% (RR = 0.72; 95% CI 0.54 to 0.97; P = 0.03), reduced length of hospital stay by 2.31 days (WMD = -2.31; 95% CI -2.50 to -2.11; P < 0.001), but did not significantly affect risk of mortality (RR = 0.92; 95% CI 0.63 to 1.34; P = 0.66). No statistical difference could be observed in the number of patients exposed to re-operation, plasma, platelets, or rate of myocardial infarction and stroke.

CONCLUSIONS

Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery.

Intra-operative blood salvage in total hip and knee arthroplasty

PURPOSE

To review records of 371 patients who underwent total hip or knee arthroplasty (THA or TKA) with intra-operative blood salvage to determine the allogeneic blood transfusion rate and the predictors for allogeneic blood transfusion.

METHODS

Records of 155 male and 216 female consecutive patients aged 17 to 95 (mean, 70) years who underwent primary THA or TKA by a single surgeon with the use of intra-operative blood salvage were reviewed.

RESULTS

The preoperative haemoglobin level was <120 g/dl in 15% of THA patients and 5% of TKA patients; the allogeneic transfusion rate was 24% in THA patients and 12% in TKA patients. Despite routine use of intra-operative blood salvage, only 59% of THA patients and 63% of TKA patients actually received salvaged blood, as a minimum of 200 ml blood loss was required to activate blood salvage. In multivariable analysis, predictors for allogeneic blood transfusion were female gender (adjusted odds ratio [OR]=2.8, p=0.02), age >75 years (adjusted OR=5.9, p<0.001), and preoperative haemoglobin level <120 g/l (adjusted OR=30.1, p<0.001), despite the use of intra-operative blood salvage. Patients who received allogeneic blood transfusion had a longer hospital stay and greater complication rate.

CONCLUSION

Intra-operative blood salvage is not effective in preventing allogeneic blood transfusion in patients with a preoperative haemoglobin level <120 g/l. It should be combined with preoperative optimisation of the haemoglobin level or use of tranexamic acid.

Post-operative Blood Salvage and Retransfusion in Total Hip and Knee Arthroplasty

This retrospective study evaluated the safety and efficacy of post-operative blood salvage and retransfusion in 430 patients undergoing total hip arthroplasty and 530 patients undergoing total knee arthroplasty. Volumes of autologous blood retransfused (mean ± SD) were 525 ± 75 and 660 ± 95 ml in the hip and knee replacement groups, respectively. Overall, 230 patients (24%) also required allogeneic blood transfusion. In a subgroup of 150 randomly selected patients, the values of free haemoglobin in the allogeneic, autologous and patients' blood at the time of surgery were 0.568 ± 0.112, 0.272 ± 0.067 and 0.032 ± 0.011 g/l, respectively. On the first and third post-operative days, the levels in patients' blood were 0.092 ± 0.039 and 0.057 ± 0.028 g/l, respectively. There were no major complications; transient chills and fever were reported in 99 (10.3%) and 115 patients (12.0%), respectively. In conclusion, post-operative blood salvage and retransfusion is a safe way to reduce the need for allogeneic blood transfusion in patients undergoing elective orthopaedic surgery.

[Two-year experience with cell salvage in total hip arthroplasty]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Postoperative Autologous Reinfusion in Total Knee Replacement

Surgeries for total knee replacement (TKR) are increasing and in this context there is a need to develop new protocols for management and use of blood transfusion therapy. Autologous blood reduces the need for allogeneic blood transfusion and the aim of the present study was to verify the safety and the clinical efficacy. An observational retrospective study has been conducted on 124 patients, undergoing cemented total knee prosthesis replacement. Observed population was stratified into two groups: the first group received reinfusion of autologous blood collected in the postoperative surgery and the second group did not receive autologous blood reinfusion. Analysis of data shows that patients undergoing autologous blood reinfusion received less homologous blood bags (10.6% versus 30%; p = 0.08) and reduced days of hospitalization (7.88 ± 0.7 days versus 8.96 ± 2.47 days for the control group; p = 0.03). Microbiological tests were negative in all postoperatively salvaged and reinfused units. Our results emphasize the effectiveness of this procedure and have the characteristics of simplicity, low cost (€97.53 versus €103.79; p < 0.01), and easy reproducibility. Use of autologous drainage system postoperatively is a procedure that allows reducing transfusion of homologous blood bags in patients undergoing TKR.

Is postoperative cell salvage necessary in total hip or knee replacement? A meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to determine whether there are hematological or clinical differences with the use of postoperative cell salvage after total knee (TKR) and hip replacement (THR).

METHODS

A systematic literature review based on PubMed, EMBASE, the Cochrane Library Database in any language regarding postoperative cell salvage following TKR or THR was performed. High quality of randomized controlled trials were identified. The data was analyzed using Rev Man 5.2.

RESULTS

19 randomized controlled trials (12 in TKR, 4 in THR and 3 in both) about 3482 patients were identified and included in this meta-analysis. Postoperative cell salvage significantly reduced the allogeneic blood transfusion requirement after TKR (RR = 0.46, 95% CI = 0.30 to 0.72) and THR (RR = 0.46, 95%CI = 0.32 to 0.68). It also demonstrated a higher level of postoperative Hemoglobin (MD = 0.26 g/dL, 95%CI = 0.15 to 0.37) with the use of postoperative cell salvage. No significant differences were detected regarding length of hospital stay, the incidence of febrile reaction, wound infection and deep vein thrombosis.

CONCLUSION

The results strengthen the fact that postoperative cell salvage is effective and safe to reduce the rate of transfusion after TKR and THR. As the relatively poor methodological quality and heterogeneity, further research is needed to confirm its safety and cost-effectiveness.

Topical Administration of Tranexamic Acid Plus Diluted-Epinephrine in Primary Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Trial

The aim of this trial was to evaluate the efficacy and safety of intra-articular administration of tranexamic acid (TXA) plus diluted-epinephrine (DEP) on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty (TKA) without drainage. One hundred patients scheduled to undergo TKA were randomized into two groups: 50 patients received intra-articular 3g TXA plus 0.25mg DEP (1:200,000), and 50 patients received 3g topical TXA alone. The results showed that topical combined administration significantly reduced total blood loss (P=0.006), hidden blood loss (P=0.000) and transfusion rate (0% vs. 4%), without increasing the risk of thromboembolic and hemodynamic complications (P>0.05). Therefore, topical TXA plus DEP was effective and safe in reducing blood loss and transfusion following TKA, without substantial complications.

Cell Salvage in Hip and Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cell salvage is used to reduce allogeneic red blood-cell (RBC) transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA). We performed a meta-analysis to assess the effectiveness of cell salvage to reduce transfusions in THA and TKA separately, and to examine whether recent trials change the conclusions from previous meta-analyses.

METHODS

We searched MEDLINE through January 2013 for randomized clinical trials evaluating the effects of cell salvage in THA and TKA. Trial results were extracted using standardized forms and pooled using a random-effects model. Methodological quality of the trials was evaluated using the Cochrane Collaboration's tool for risk-of-bias assessment.

RESULTS

Forty-three trials (5631 patients) were included. Overall, cell salvage reduced the exposure to allogeneic RBC transfusion in THA (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.51 to 0.85) and TKA (RR, 0.51; 95% CI, 0.39 to 0.68). However, trials published in 2010 to 2012, with a lower risk of bias, showed no significant effect of cell salvage in THA (RR, 0.82; 95% CI, 0.66 to 1.02) and TKA (RR, 0.91; 95% CI, 0.63 to 1.31), suggesting that the treatment policy regarding transfusion may have changed over time.

CONCLUSIONS

Looking at all trials, cell salvage still significantly reduced the RBC exposure rate and the volume of RBCs transfused in both THA and TKA. However, in trials published more recently (2010 to 2012), cell salvage reduced neither the exposure rate nor the volume of RBCs transfused in THA and TKA, most likely explained by changes in blood transfusion management.

Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management.

Supplemental Digital Content is available in the text.

Two-year experience with cell salvage in total hip arthroplasty

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Patient blood management in elective total hip- and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients

BACKGROUND

Patient blood management combines the use of several transfusion alternatives. Integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices on allogeneic erythrocyte use was evaluated using a restrictive transfusion threshold.

METHODS

In a factorial design, adult elective hip- and knee-surgery patients with hemoglobin levels 10 to 13 g/dl (n = 683) were randomized for erythropoietin or not, and subsequently for autologous reinfusion by cell saver or postoperative drain reinfusion devices or for no blood salvage device. Primary outcomes were mean allogeneic intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness.

RESULTS

With erythropoietin (n = 339), mean erythrocyte use was 0.50 units (U)/patient and transfusion rate 16% while without (n = 344), these were 0.71 U/patient and 26%, respectively. Consequently, erythropoietin resulted in a nonsignificant 29% mean erythrocyte reduction (ratio, 0.71; 95% CI, 0.42 to 1.13) and 50% reduction of transfused patients (odds ratio, 0.5; 95% CI, 0.35 to 0.75). Erythropoietin increased costs by €785 per patient (95% CI, 262 to 1,309), that is, €7,300 per avoided transfusion (95% CI, 1,900 to 24,000). With autologous reinfusion, mean erythrocyte use was 0.65 U/patient and transfusion rate was 19% with erythropoietin (n = 214) and 0.76 U/patient and 29% without (n = 206). Compared with controls, autologous blood reinfusion did not result in erythrocyte reduction and increased costs by €537 per patient (95% CI, 45 to 1,030).

CONCLUSIONS

In hip- and knee-replacement patients (hemoglobin level, 10 to 13 g/dl), even with a restrictive transfusion trigger, erythropoietin significantly avoids transfusion, however, at unacceptably high costs. Autologous blood salvage devices were not effective.

Quick biochemical markers for assessment of quality control of intraoperative cell salvage: a prospective observational study

BACKGROUND

Intraoperative Cell Salvage (ICS), hereby referred to 'mechanical red cell salvage', has been widely used in adult elective major surgeries to reduce requirement for homologous red blood cell transfusion and its associated complications. However, amount of free haemoglobin (fHb) from ICS has been shown related to incidence of renal failure. fHb is the most important indicator of quality control of cell salvaged blood, thus monitoring the fHb concentration is imperative to minimise renal injury. However, currently there has been lacking quick biochemical markers to monitor the levels of fHb during ICS. The aim of this study was to screen quick biochemical markers for evaluating the amount of fHb during use of intraoperative cell salvage.

METHODS

Twenty patients undergoing elective cardiovascular surgery were enrolled. Blood was collected and processed using a Fresenius continuous auto-transfusion system device. The concentration of fHb, albumin (Alb), and calcium (Ca) in three washing modes were measured, and their clearance rates were calculated. The correlations among the clearances and concentrations of fHb, albumin, and calcium were analysed.

RESULTS

In three washing modes, concentrations of albumin and calcium are significantly associated with amount of fHb:fHb(g/L) = 0.111 Alb(g/L) -0.108, R = 0.638, p = 0.000; fHb(g/L) = 1.721 Ca(mmol/L) +0.091, R = 0.514, p = 0.000. Furthermore, the clearance rates of albumin and calcium significantly predict clearance of fHb, CR(fHb) = 0.310 CR(ALB) + 0.686, R = 0.753, p = 0.000, CR(fHb) = 0.073 CR(Ca) + 0.913, R = 0.497, p = 0.000.

CONCLUSIONS

In clinic practice, clearance rates of albumin, or calcium can be used to evaluate the quality of salvaged blood, fHb. Bed-side measurement of calcium could offer a more feasible means for clinicians to undertake a real-time assessment of fHb.

Patient Blood Management in Elective Total Hip- and Knee-replacement Surgery (Part 2)

Background:

Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion.

Methods:

Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness.

Results:

In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by €298 per patient (95% CI, 76 to 520).

Conclusion:

In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.

The merits of cell salvage in arthroplasty surgery: an overview

Arthroplasty entails considerable exposure to allogenic blood transfusion. Cell salvage with washing is a contemporary strategy that is not universally used despite considerable potential benefits. We searched Embase and Medline to determine if blood salvage with washing during primary and/or revision hip and knee arthroplasty results in lower rates of transfusion and postoperative complications. We included 10 studies in our analysis, which we rated according to Downs and Black criteria. With primary knee arthroplasty, there was a reduction in transfusion rate from 22% to 76% and a 48% reduction in transfusion volume (n = 887). With primary hip arthroplasty, there was a reduction from 69% to 73% in transfusion rate and a 31% reduction in transfusion volume (n = 239). There was a significant decrease in length of hospital stay (9.6 v. 13.6 d). Studies of revision arthroplasty reported a 31%-59% reduction in transfusion volume (n = 241). The available evidence demonstrates reduced exposure to allogenic blood with the use of salvage systems. Studies have been underpowered to detect differences in infection rates and other postoperative complications. Future cost analysis is warranted.

Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty

BACKGROUND

Up to 70% of patients who undergo total hip or total knee arthroplasty receive blood transfusions. Using data from more than 12,000 patients assessed in the Phase-III RECORD (Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism) studies, we investigated whether allogeneic blood transfusion increases the risk of postoperative infection compared with autologous blood transfusion or no transfusion.

METHODS

A post hoc analysis of the pooled RECORD data stratified patients into three groups according to the type of blood transfusion that they received: no transfusion (n = 6313), autologous blood transfusion (n = 1902), and allogeneic blood transfusion with or without autologous blood transfusion (n = 3962). The types of postoperative infection were recorded and included lower or upper respiratory tract and lung infection, bone and joint infection, wound inflammation or infection, urinary tract infection, and other infections.

RESULTS

The rates of infection in patients receiving no transfusion or autologous blood transfusion were similar; therefore, data from these two groups were combined. The rate of any infection was 9.9% (392 of 3962) in patients receiving allogeneic blood transfusion and 7.9% (646 of 8215) in patients not receiving allogeneic blood transfusion with or without autologous blood transfusion (p = 0.003). The rates of lower or upper respiratory tract and lung infection (2.1% [eighty-five of 3962] versus 1.3% [109 of 8215]; p = 0.002) and of wound inflammation or infection (2.4% [ninety-four of 3962] versus 1.7% [138 of 8215]; p = 0.046) were significantly higher in patients receiving allogeneic blood transfusion compared with patients not receiving allogeneic blood transfusion. When comparing patients who had received allogeneic blood transfusion with those who had not received allogeneic blood transfusion, the rates of bone and joint infection (0.4% [fourteen of 3962] versus 0.2% [eighteen of 8215]; p = 0.056), of urinary tract infection (3.1% [123 of 3962] versus 2.5% [209 of 8215]; p = 0.551), and of other infections (3.0% [120 of 3962] versus 2.7% [225 of 8215]; p = 0.308) were not significantly different.

CONCLUSIONS

The rates of any infection, lower or upper respiratory tract and lung infection, and wound inflammation or infection were significantly increased after elective total hip or total knee arthroplasty in patients receiving allogeneic blood transfusion compared with those receiving autologous blood transfusion or no blood transfusion.

Intraoperative cell salvage in revision hip surgery

Allogenic blood is a finite resource, with associated risks. Previous studies show intraoperative cell salvage (ICS) can reduce allogenic transfusion rates in orthopaedic surgery. However, there are concerns regarding efficacy and cost-effectiveness of ICS. This study was carried out to review ICS use in revision hip arthroplasty. All patients who underwent ICS and re-infusion between 2008 and 2010 in the Southern General Hospital (SGH) were audited. The fall in haemoglobin (Hb), volume of blood re-infused and postoperative allogenic transfusion rates were recorded. This group was compared to a similar SGH cohort who underwent surgery by the same surgeons between 2006 and 2008, and a pre-2005 control group where no ICS was used. The proportion of patients receiving a postoperative allogenic transfusion fell by 55% in the 2008-2010 ICS cohort compared with the control, and by 40% compared with the previous ICS group. In both instances, there was a statistically significant (p < 0.001) reduction in mean units transfused per patient; in the 2008-2010 ICS cohort, a mean of 0.8 units was used per patient, while 1.4 were used in the 2006-2008 cohort. 3.5 units were used in the control group. There was no statistically significant difference in age or preoperative Hb between the groups, or in length of hospital stay. In this study, ICS has been shown to be effective in reducing rates and volume of postoperative allogenic transfusion in patients undergoing revision hip surgery at the SGH. However, further work is needed to establish the effect of changing anaesthetic technique on postoperative allogenic transfusion rates.

The effect of autotransfusion system in minimally invasive total knee arthroplasty

Purpose

To evaluate the effect of autotransfusion system in minimally invasive total knee arthroplasty (TKA).

Materials and Methods

Seventy-one patients who underwent unilateral minimally invasive TKA between October 2009 and June 2010 were selected. The first group included 36 patients who received standard vacuum drainage and the second group, 35 patients who underwent autologous retransfusion drainage. In the first group, allogeneic blood transfusion was performed if the postoperative hemoglobin level was <7.0 g/dL or 7.0-8.0 g/dL with the presence of a medical complication and an anemic symptom. The second group received autotransfusion and allogeneic transfusion additionally according to the same criteria. Changes in the pre- and postoperative hemoglobin level, amount of auto- or allotransfusion, and frequency of allogeneic transfusion were assessed.

Results

Allogeneic transfusion was required in 13 patients (36.1%) in the first group and four patients (11.4%) in the second group. The mean allogeneic transfusion volume was significantly low in the second group compared to the first group (64.4 mL vs. 278.9 mL; p<0.05). The hemoglobin level on the 1st postoperative day compared to the preoperative level decreased by 22.6% in the first group and 11.7% in the second group. The postoperative hemoglobin level was higher in the second group (p<0.05).

Conclusions

Minimally invasive unilateral TKA with an autotransfusion system can be beneficial in patients with no medical complications because of the decreased allogeneic transfusion.

The cost of post-operative shed blood salvage after total knee arthroplasty: an analysis of 1,093 consecutive procedures

BACKGROUND

Requirements for allogeneic red cell transfusion after total knee arthroplasty are still high (20-50%), and salvage and reinfusion of unwashed, filtered post-operative shed blood is an established method for reducing transfusion requirements following this operation. We performed a cost analysis to ascertain whether this alternative is likely to be cost-effective.

MATERIALS AND METHODS

Data from 1,093 consecutive primary total knee arthroplasties, managed with (reinfusion group, n=763) or without reinfusion of unwashed salvaged blood (control group, n=330), were retrospectively reviewed. The costs of low-vacuum drains, shed blood collection canisters (Bellovac ABT, Wellspect HealthCare and ConstaVac CBC II, Stryker), shed blood reinfusion, acquisition and transfusion of allogeneic red cell concentrate, haemoglobin measurements, and prolonged length of hospital stay were used for the blood management cost analysis.

RESULTS

Patients in the reinfusion group received 152±64 mL of red blood cells from postoperatively salvaged blood, without clinically relevant incidents, and showed a lower allogeneic transfusion rate (24.5% vs. 8.5%, for the control and reinfusion groups, respectively; p =0.001). There were no differences in post-operative infection rates. Patients receiving allogeneic transfusions stayed in hospital longer (+1.9 days [95% CI: 1.2 to 2.6]). As reinfusion of unwashed salvaged blood reduced the allogeneic transfusion rate, both reinfusion systems may provide net savings in different cost scenarios (€ 4.6 to € 106/patient for Bellovac ABT, and € -51.9 to € 49.9/patient for ConstaVac CBCII).

DISCUSSION

Return of unwashed salvaged blood after total knee arthroplasty seems to save costs in patients with pre-operative haemoglobin between 12 and 15 g/dL. It is not cost-saving in patients with a pre-operative haemoglobin >15 g/dL, whereas in those with a pre-operative haemoglobin <12 g/dL, although cost-saving, its efficacy could be increased by associating some other blood-saving method.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

Knee arthroplasty and bleeding: when to remove drainages

PURPOSE

The aim of this study is an attempt to clarify the productive time of drainages as we find that the use of drains in knee arthroplasty is controversial, and there is no consensus regarding their length-time maintenance. We analysed the survival curve of bleeding within three surgical techniques for knee arthroplasty and the effect of two variables on survival curve.

METHODS

One hundred and eighty-eight out of 234 knees were included in the study, and patients were divided into three groups according to the surgical technique: conventional total knee arthroplasty (TKA), subvastus TKA and unicompartmental knee arthroplasty. Variables of study were type of surgery, number and placement of drains.

RESULTS

Mean of survival curve for postoperative bleeding time was 16 h (95 % CI: 15.4; 16.6). The risk for longer bleeding increased 1.38-fold with each additional drain used (95 % CI 1.1; 1.8).

CONCLUSIONS

According to the present study, drains can be safely removed at around 17 h postoperative. Bleeding time reduces as less drains are applied.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Post-operative auto-transfusion in total hip or knee arthroplasty: a meta-analysis of randomized controlled trials

BACKGROUND

Total hip or knee arthroplasty is an elective procedure that is usually accompanied by substantial blood loss, which may lead to acute anemia. As a result, almost half of total joint arthroplasty patients receive allogeneic blood transfusions (ABT). Many studies have shown that post-operative auto-transfusion (PAT) significantly reduces the need for ABT, but other studies have questioned the efficacy of this method.

METHODS

The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1. To evaluate the efficacy of PAT, we conducted a Cochrane systematic review that combined all available data from randomized controlled trials. Data from the six included trials were pooled for analysis. We then calculated relative risks with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences with 95% CIs for continuous outcomes.

FINDINGS AND CONCLUSION

To our knowledge, this is the first meta-analysis to compare the clinical results between PAT and a control in joint replacement patients. This meta-analysis has proven that the use of a PAT reinfusion system reduced significantly the demand for ABT, the number of patients who require ABT and the cost of hospitalization after total knee and hip arthroplasty. This study, together with other previously published data, suggests that PAT drains are beneficial. Larger, sufficiently powered studies are necessary to evaluate the presumed reduction in the incidence of infection as well as DVT after joint arthroplasty with the use of PAT.

A cost study of postoperative cell salvage in the setting of elective primary hip and knee arthroplasty

BACKGROUND

The increasing costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as postoperative red blood cell (RBC) salvage. This study provides a cost comparison of transfusing washed postoperatively salvaged RBCs using an orthopedic perioperative autotransfusion device (OrthoPat, Haemonetics Corporation) versus unwashed shed blood and banked allogeneic blood.

STUDY DESIGN AND METHODS

Cell salvage data were retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Mean unit costs were calculated for washed salvaged RBCs, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic RBCs.

RESULTS

No initial capital investment was required for the establishment of the postoperative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $1827.41, $1167.41, and $2609.44, respectively.

CONCLUSION

This analysis suggests that transfusing washed postoperatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed postoperatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.

Cell salvage as part of a blood conservation strategy in anaesthesia

The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.

Sedimentation method for preparation of postoperatively salvaged unwashed shed blood in orthopaedic surgery

BACKGROUND

Salvage and return of unwashed shed blood (USB) after total knee replacement (TKR) is an established blood-saving technique, but some authors question its efficacy and safety and suggest that the shed blood be washed before returning. We evaluated a colloid-based sedimentation method for improving and standardizing the quality of USB collected after TKR without the need for washing.

METHODS

Experiments were performed to find the optimal colloid dose and sedimentation time using diluted donated venous blood. USB samples (n=52) were drawn from the reinfusion bag and mixed with hydroxyethyl starch or gelatine solutions (15-30%, colloid solution volume/total volume × 100). USB red blood cells (RBCs) were allowed to settle by gravity for 30 min, supernatant was evacuated from the syringe, and RBC concentrate was analysed. RBC recovery and other blood cell and chemical removal were calculated according to changes in USB volume and haematocrit. Twenty-five samples from leucodepleted packed RBCs were analysed as a comparator group.

RESULTS

Mean haemoglobin (Hb) of USB was 10.9 g dl(-1). After colloid treatment, 90% of RBCs were recovered, and USB Hb was similar to that of leucodepleted packed RBCs (n=25) (18.9 vs 19.6 g dl(-1), respectively; P=NS). In addition, the procedure reduced USB content of leucocytes (60%), platelets (48%), total protein (76%), cytokines (70-77%), and plasma-free haemoglobin (53%), without major differences between colloids.

CONCLUSIONS

Sedimentation of USB with colloid solutions provides a low-cost alternative for improving and standardizing the quality of salvaged USB after TKR.

Is peri-articular multimodal drug infiltration in knee arthroplasty safe when used in conjunction with autologous retransfusion drains?

INTRODUCTION

Adequate peri-operative analgesia following total knee arthroplasty (TKA) promotes earlier rehabilitation but remains problematic because of the drug side-effects. Peri-articular multimodal drug infiltration (PMDI) has been developed as an alternative strategy to avoid such complications. Autologous retransfusion drains reduce the need for peri-operative allogenic blood transfusions and the consequent risk. There is a theoretical risk of local anaesthesia toxicity when these systems are used concurrently. We performed a review of current practice to quantify this risk.

PATIENTS AND METHODS

A series of 10 patients undergoing TKA by the senior author (CAB) had drain fluid analysed for the concentration of ropivacaine. At the same time, the patients completed a questionnaire to establish the presence of ropivacaine-induced side-effects.

RESULTS

The ropivacaine level in the retransfusion blood was less than 10 mg in all patients. This concentration was a factor of 6 below the published safe level. Three patients had minor neurological disturbances which recovered spontaneously and quickly. There were no cases of significant cardiovascular compromise.

CONCLUSIONS

The theoretical risk of local anaesthesia toxicity when these systems are used together is negligible and we conclude that peri-articular multimodal drug infiltration is safe in conjunction with the use of autotransfusion drains.

Prospective comparative study of two different autotransfusion methods versus control group in total knee replacement

AIM

The aim of this study was to evaluate the efficacy of two different autotransfusion methods in total knee replacement (TKR) performed without tourniquet, in comparison to allogeneic blood transfusion (ABT) only.

METHOD

In a comparative study, 248 patients with knee osteoarthritis were randomized in three groups: in control Group 85 the patients underwent only ABT post-operatively, in Group 1 (n:92) an intraoperative and postoperative autotransfusion were utilized, and in Group 2 (n:71) only a postoperative autotransfusion was applied. Post-operative ABT was utilized according to predetermined criteria.

RESULTS

Comparing Group 0 to Group 1 and 2 the difference in need for ABT post-operatively was statistically highly significant (p < 0.001) even when the results were analyzed classifying the patients according to the preoperative Hb levels. The difference between Group 1 and 2 was not significant.

CONCLUSION

According to the results of this study, auto-transfusion reduces the need for ABT in TKR performed without tourniquet.

Cell salvage for minimising perioperative allogeneic blood transfusion

BACKGROUND

Concerns regarding the safety of transfused blood have prompted reconsideration of the use of allogeneic (from an unrelated donor) red blood cell (RBC) transfusion, and a range of techniques to minimise transfusion requirements.

OBJECTIVES

To examine the evidence for the efficacy of cell salvage in reducing allogeneic blood transfusion and the evidence for any effect on clinical outcomes.

SEARCH STRATEGY

We identified studies by searching CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1950 to June 2009), EMBASE (1980 to June 2009), the internet (to August 2009) and bibliographies of published articles.

SELECTION CRITERIA

Randomised controlled trials with a concurrent control group in which adult patients, scheduled for non-urgent surgery, were randomised to cell salvage (autotransfusion) or to a control group who did not receive the intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and the risk of bias assessed. Relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random-effects model. The primary outcomes were the number of patients exposed to allogeneic red cell transfusion and the amount of blood transfused. Other clinical outcomes are detailed in the review.

MAIN RESULTS

A total of 75 trials were included. Overall, the use of cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 38% (RR 0.62; 95% CI 0.55 to 0.70). The absolute reduction in risk (ARR) of receiving an allogeneic RBC transfusion was 21% (95% CI 15% to 26%). In orthopaedic procedures the RR of exposure to RBC transfusion was 0.46 (95% CI 0.37 to 0.57) compared to 0.77 (95% CI 0.69 to 0.86) for cardiac procedures. The use of cell salvage resulted in an average saving of 0.68 units of allogeneic RBC per patient (WMD -0.68; 95% CI -0.88 to -0.49). Cell salvage did not appear to impact adversely on clinical outcomes.

AUTHORS' CONCLUSIONS

The results suggest cell salvage is efficacious in reducing the need for allogeneic red cell transfusion in adult elective cardiac and orthopaedic surgery. The use of cell salvage did not appear to impact adversely on clinical outcomes. However, the methodological quality of trials was poor. As the trials were unblinded and lacked adequate concealment of treatment allocation, transfusion practices may have been influenced by knowledge of the patients' treatment status potentially biasing the results in favour of cell salvage.

Cell salvage for minimising perioperative allogeneic blood transfusion

BACKGROUND

Concerns regarding the safety of transfused blood, have prompted reconsideration of the use of allogeneic (blood from an unrelated donor) red blood cell (RBC) transfusion, and a range of techniques to minimise transfusion requirements.

OBJECTIVES

To examine the evidence for the efficacy of cell salvage in reducing allogeneic blood transfusion and the evidence for any effect on clinical outcomes.

SEARCH STRATEGY

We identified studies by searching CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1950 to June 2009), EMBASE (1980 to June 2009), the Internet (to August 2009) and bibliographies of published articles.

SELECTION CRITERIA

Randomised controlled trials with a concurrent control group in which adult patients, scheduled for non-urgent surgery, were randomised to cell salvage (autotransfusion), or to a control group, who did not receive the intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and the risk of bias assessed. Relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary outcomes were the number of patients exposed to allogeneic red cell transfusion, and the amount of blood transfused. Other clinical outcomes are detailed in the review.

MAIN RESULTS

A total of 75 trials were included. Overall, the use of cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 38% (RR=0.62: 95% CI 0.55 to 0.70). The absolute reduction in risk (ARR) of receiving an allogeneic RBC transfusion was 21% (95% CI 15% to 26%). In orthopaedic procedures the RR of exposure to RBC transfusion was 0.46 (95% CI 0.37 to 0.57) compared to 0.77 (95% CI 0.69 to 0.86) for cardiac procedures. The use of cell salvage resulted in an average saving of 0.68 units of allogeneic RBC per patient (WMD=-0.68; 95% CI -0.88 to -0.49). Cell salvage did not appear to impact adversely on clinical outcomes.

AUTHORS' CONCLUSIONS

The results suggest cell salvage is efficacious in reducing the need for allogeneic red cell transfusion in adult elective cardiac and orthopaedic surgery. The use of cell salvage did not appear to impact adversely on clinical outcomes. However, the methodological quality of trials was poor. As the trials were unblinded and lacked adequate concealment of treatment allocation, transfusion practices may have been influenced by knowledge of the patients' treatment status potentially biasing the results in favour of cell salvage.

Dutch orthopedic blood management surveys 2002 and 2007: an increasing use of blood-saving measures

BACKGROUND

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007.

STUDY DESIGN AND METHODS

In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively).

RESULTS

The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6–66.1%) as well as knee (24.0–55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3–28.4%) as well as knee arthroplasty (8.9–16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5–51.0%) and knee arthroplasty (15.9–59.3%).

CONCLUSION

There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.