The impact of preoperative autologous blood donation on orthopaedic surgical practice

Blood conservation strategies in orthopedic surgeries: A review

In orthopedics management of surgical blood loss is an important aspect which has evolved along with modern surgeries. Replacement of lost blood by transfusion alone is not the answer as was considered earlier. Complications like infection and immune reaction due to blood transfusion are a major concern. Today numerous techniques are available in place of allogenic blood transfusion which can be employed safely and effectively. In this article we have reviewed these techniques, their merits and demerits.

Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications

Preoperative autologous blood donation (PABD) is a well established transfusion practice in elective orthopaedic surgery, involving immunologic and infective advantages but also involving exposure to not negligible risks, and costs as well. The aim of this study was to assess the real need for blood transfusions in primary total knee arthroplasty (TKA). Between January 2000 and July 2005, 214 patients underwent primary unilateral TKA. Altogether, 416 autologous blood units were collected, however only 47 (11.3%) were transfused. Thirty-eight patients (17.8%) received autologous blood, while 4 of them (10.5%) also received allogeneic blood. Based on the results of this study, PABD should be recommended in well selected patients undergoing TKA: older female patients with a low basal haemoglobin level.

Ten years of preoperative autologous blood donation in accra

SUMMARY BACKGROUND

Preoperative autologous blood donation (PABD) is utilized to circumvent the use of allogenic blood for various reasons.

OBJECTIVE

To describe the distribution in terms of demographic characteristic, trends in participation and result of screening test of the PABD programme of the Accra Area Blood Center from 1993-2003.

DESIGN AND SETTING

Retrospective descriptive study of PABD in patients scheduled for a variety of elective surgical procedures.

SETTING

Different levels of institutional health care in Accra, Ghana.

METHODS

Data from existing records of patients who had participated in PABD were collated and analyzed

RESULTS

Five hundred and forty six (546) females and 89 males participated, with ages ranging between 14-74 years. Majority of the patients (76.7%) underwent gynaecological surgery. A total of 330 (52%) donated one unit only, and 299 (47.1%) donated two units. Majority of the patients (56.4%) had the surgery at the Korle-Bu Teaching Hospital (KBTH). Of the donations, 21 (3.3%), 1 (0.2%), 1 (0.3%) and nil were positive for HBV, HIV I & II, HCV and VDRL respectively. A total of 848 (89.4%) autologous cross-matched units were issued out. There was a steady progressive increase in participation.

CONCLUSION

Mainly adult females scheduled for gynaecological surgeries in KBTH participated, while almost equal proportions donated one or two units of blood which meets the blood needs of most elective surgeries. Therefore healthy patients going for elective surgeries in regions with limited blood supply must be encouraged to enter a PABD Programme. Further studies in this field should evaluate motivational factors for participation.

Blood loss minimization and blood salvage techniques for complex spinal surgery

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.

Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective, case-control.

OBJECTIVE

Evaluate the utility of preoperative autologous blood donation (PABD) for surgical treatment of adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Recent data have highlighted overuse of PABD in elective surgery; however, PABD is a major blood conservation strategy for AIS surgery.

METHODS

Medical records of 123 patients treated for AIS between June 1995 and November 2004 were reviewed. Patients were divided into PABD (n = 104) and nondonors (NPABD; n = 19).

RESULTS

No differences existed between PABD and NPABD for age, major curve size, or operative procedures. Average PABD preoperative hematocrit was lower than NPABD (37.8 vs. 40.2; P < 0.005). PABD patients were 9 times more likely to be transfused than NPABD, and 3 times more likely to be transfused for each unit donated. There was a 25% transfusion risk reduction for each percent preoperative hematocrit increase. Minimum one autologous unit was not transfused in 32 patients (31%). Twenty-nine PABD patients (28%) were transfused for hematocrit >30. Fifty-three PABD patients (51%) wasted at least one unit or were transfused for hematocrit >30.

CONCLUSIONS

The majority of PABD patients (51%) wasted minimum one autologous unit or were transfused at a high hematocrit (>30). More precise PABD guidelines are needed to limit unnecessary transfusion and wasted resources.

Preoperative autologous blood donation in primary total knee arthroplasty: a single-centre experience on 214 consecutive patients

BACKGROUND AND OBJECTIVES

Although preoperative autologous blood donation (PABD) is a widespread practice in elective orthopedic surgery, it is controversial whether this procedure avoids allogeneic blood transfusions in patients undergoing total knee arthroplasty (TKA).

PATIENTS AND METHODS

We performed a retrospective study on 214 consecutive patients undergoing PABD before elective primary TKA.

RESULTS

Thirty-eight patients (17.8%) were transfused with autologous red blood cells (RBC), while four of them (10.5% of those requiring transfusions, 1.9% of all patients) also received allogeneic RBC. The transfused patients were, in most cases, female and had significantly lower basal and preoperative haemoglobin levels.

CONCLUSIONS

Based on the results of this study, PABD is not necessary in most patients undergoing TKA, although older female patients with low basal haemoglobin levels could benefit from a predeposit programme and/or erythropoietin support in order to reduce the risk of exposure to allogeneic blood.

Perioperative blood and blood product management for spinal deformity surgery

BACKGROUND CONTEXT

Spinal deformity surgery, like many other orthopedic procedures, involves significant operative blood loss. In order to avoid the necessity of bank blood transfusions, many blood management strategies have been devised.

PURPOSE

The goal of this review is to analyze the utility of current blood management strategies.

STUDY DESIGN/SETTING

Review paper.

METHODS

Using Medline reviews, pertinent data on blood management agents and strategies were assembled.

RESULTS

Techniques can be organized into preoperative, intraoperative and postoperative categories. Preoperative techniques include autologous blood donation and red cell augmentation. In addition to some established surgical and anesthesia techniques, recent pharmacologic agents have become available to include thrombotic agents and antifibrinolytics, which surgeons may add to their intraoperative armamentarium. A brief mention of postoperative blood salvage drains is also included.

CONCLUSIONS

The judicious use of the agents and techniques can significantly reduce the need for blood transfusions in the setting of spinal deformity surgery.

Increased serum erythropoietin concentration after allogeneic compared with autologous blood transfusion

Serum erythropoietin (sEPO) level is known to increase as hemoglobin (Hb) concentration decreases during and after preoperative autologous blood donation (PAD). The endogenous erythropoietin (EPO) production after allogeneic blood transfusion has not to our knowledge, been studied. The aim of the present study was to determine whether there is, after surgery, any change in sEPO concentration after allogeneic blood transfusion, and whether there is any difference in EPO response after autologous or allogeneic blood transfusion. Thirty-one patients approaching total hip-joint replacement surgery, were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). The relationship between Hb, sEPO, and reticulocytes in the recipients were repeatedly analyzed before, during and after surgery. The Hb followed an expected pattern, with a decreased concentration after PAD in the autologous group, then in both groups after surgery. The sEPO concentration was significantly higher in the allogeneic than in the autologous group on day one and day 4-5 postoperatively. The reticulocyte level, on the contrary, was higher in the autologous patients before, one hour after, and one day after surgery. The study showed a greater increase in sEPO concentration after allogeneic blood transfusion than after autologous blood transfusion. There may be an inverse relationship between sEPO and the reticulocyte level.

Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries

STUDY DESIGN

A retrospective study of blood transfusion practices after posterior lumbar spine surgery was performed.

OBJECTIVES

To determine the overall use rate of autologous blood donations for different spine surgeries, and to identify the risk of requiring additional allogeneic blood transfusions.

SUMMARY OF BACKGROUND DATA

In an attempt to avoid allogeneic blood transfusions and its associated risks, patients frequently are asked to donate autologous blood before many elective spine surgeries. There is a lack of published data on the use rate for these autologous blood donations, and on their ability to prevent allogeneic blood exposure.

METHODS

A retrospective review of hospital charts and blood bank records was conducted on 191 consecutive patients who had undergone three categories of lumbar spine surgery: laminectomy alone, laminectomy with a noninstrumented posterolateral fusion, and laminectomy with an instrumented posterolateral fusion.

RESULTS

Nearly 80% of the autologous blood donated by patients who underwent simple laminectomies was wasted. However, the vast majority (70-90%) of patients who underwent fusion used their autologous blood. In the patients who underwent fusion, autologous blood donations decreased the risk of allogenic blood transfusions by 75% in noninstrumented fusions and 50% in instrumented fusions, as compared with the patients who elected not to donate blood before the fusion (P < 0.05). A substantial number of patients who underwent instrumented fusions (nearly 40%) required additional allogeneic blood transfusions despite predonation of blood.

CONCLUSIONS

Autologous blood donations are indeed advantageous in decreasing allogeneic blood usage of patients undergoing fusion, but additional methods of blood conservation (intraoperative salvage and preoperative erythropoietin) seem necessary to diminish the allogeneic blood requirements further, especially in those patients undergoing instrumented lumbar fusion.

Autologous blood transfusion in total knee replacement surgery

We compared allogeneic blood usage for two groups of patients undergoing total knee replacement surgery (TKR). Patients were randomized to receive either their post-operative wound drainage as an autotransfusion (n=115) after processing or to have this wound drainage discarded (n=116). Allogeneic blood was transfused in patients of either group whose haemoglobin fell below 9 g dl(-1). Only 7% of patients in the autotransfusion group required an allogeneic transfusion compared with 28% in the control group (P<0.001). There was no hospital mortality and only 3% mortality from all causes at the study completion, which spanned 6 months to 3 yr. There was a higher incidence of infection requiring intervention in the allogeneic group (P<0.036). Total patient costs were Pound Sterling 113 greater in the autotransfusion group. We conclude that in this type of surgery post-operative cell salvage is a safe and effective method for reducing allogeneic blood use.

Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement

STUDY OBJECTIVE

To determine the frequency of allogeneic transfusion for total hip replacement (THR) surgery and to examine the efficacy of preoperative autologous blood donation (PABD) under specified, standardized blood transfusion guidelines.

DESIGN

Prospective, nonrandomized study.

SETTING

University medical center.

PATIENTS

All ASA physical status I, II, III, and IV patients undergoing single, primary, THR surgery from April 1998 to March 1999.

INTERVENTIONS

All patients received standardized transfusion and anticoagulation therapy. Demographic, blood loss, and transfusion data were collected and compared between all patients participating in PABD (donors) and patients not participating in PABD (nondonors). Overall allogeneic blood exposure was established. Since most anemic patients could not participate in PABD, allogeneic transfusion frequency was also examined in a subset of nonanemic patients (hemoglobin > or =12 g/dL) who were potentially able to participate in PABD.

MEASUREMENTS AND MAIN RESULTS

n = 231 patients, 142 donors and 89 nondonors. Mean estimated blood volume (EBV) of donors was 4991 +/- 1042 mL versus nondonors 4631 +/- 1108 mL (p < 0. 01). ASA physical status I-II/III-IV among donors was 118/24 versus nondonors 61/28 (p < 0.01). Overall allogeneic blood exposure was 22% (51/231). Allogeneic transfusion frequency for all donors was 15% (22/142) versus nondonors 33% (29/89) (p < 0.05). Among nonanemic patients, donor versus nondonor EBV and ASA physical status I-II/III-IV were 5074 +/- 1019 mL versus 4743 +/- 1172 mL and 107/20 versus 48/15 (p = NS); allogeneic transfusion frequency reduced to 13% (16/127) versus 17% (11/63) (p = NS), respectively.

CONCLUSIONS

Allogeneic blood exposure was >10% despite the use of PABD. The efficacy of PABD has been obscured by the fact that donors of autologous blood tend to be larger and healthier than nondonors. After exclusion of anemic patients, autologous donors and nondonors were clinically comparable and the difference in allogeneic blood exposure was not statistically significant. PABD offers only a modest, if any, benefit for THR surgery.

A randomized trial comparing acute normovolemic hemodilution and preoperative autologous blood donation in total hip arthroplasty

BACKGROUND

The value of acute normovolemic hemodilution (ANH) as compared to preoperative autologous blood donation (PABD) in orthopedic surgery is unknown. Therefore, a prospective, randomized study was conducted to compare these techniques in patients undergoing primary total hip arthroplasty.

STUDY DESIGN AND METHODS

ANH patients underwent phlebotomy for up to 3 units, or to a target Hct level of 28 percent after induction of anesthesia. PABD patients were asked to donate up to 3 units before admission.

RESULTS

Mean baseline Hct levels were not different in ANH and PABD patients (39. 7 +/- 4.5 vs. 41.8 +/- 3.8%, p = 0.09). No difference was found in allogeneic blood exposure among ANH and PABD cohorts: 4 (17%) of 23 ANH patients received a total of 9 allogeneic blood units, compared to no allogeneic transfusions in the PABD cohort (p = 0.30). Total blood costs associated with ANH were significantly (p<0.05) lower than blood costs associated with PABD ($151 +/- 154 vs. $680 +/- 253, respectively).

CONCLUSION

In patients undergoing total hip arthroplasty, ANH is safe, can be considered equivalent to PABD in effectively reducing exposure to allogeneic RBCs, and is less costly than PABD.

Blood conservation in patients undergoing non-cardiac surgery

Concerns about the safety, inventory, and cost of allogeneic blood have led to a renewed interest in blood conservation. Autologous blood collection techniques, including preoperative autologous donation, acute normovolemic hemodilution, and perioperative blood recovery are routinely used as alternatives to allogeneic transfusion. In the future, these techniques may be combined with pharmacological strategies, such as presurgical erythropoietin therapy or red cell substitutes, to reduce further the need for allogeneic blood.

A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators

Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective.

IMPLICATIONS

This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.

A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators

Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective.

IMPLICATIONS

This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.

Preoperative autologous blood donation by 1073 elderly patients undergoing elective surgery: a safe and effective practice

BACKGROUND

Preoperative autologous blood donation (PABD) aims at avoiding the risks associated with exposure to allogeneic blood. While its use is extremely common among adult patients in connection with elective surgery, it is still uncommon in elderly patients, because of a series of coexisting pathologies.

STUDY DESIGN AND METHODS

A retrospective study was made of 1073 consecutive elderly patients at a city hospital from 1990 to 1996. Their responses to the PABD program were evaluated by analysis of the incidence of complications and the demand for allogeneic blood.

RESULTS

The PABD program was interrupted in 79 (7.4%) of 1073 patients because of the onset of anemia, vasovagal reactions, lack of accessible superficial veins, or cardiovascular complications. Seven hundred eighty-four (73.1%) of 1073 patients were given autologous blood; 151 (14.1%) patients also required allogeneic blood.

CONCLUSION

The onset of anemia (6.5%) was the main contraindication for continuing the PABD program: incidence increased with age. PABD in connection with elective surgery is both feasible and effective in a high percentage of elderly patients.

Blood management experience: relationship between autologous blood donation and transfusion in orthopedic surgery

Preoperative autologous donation (PAD) is commonly used for patients undergoing elective total joint arthroplasty; however, PAD is associated with increased overall transfusion rates and may not be cost-effective for all patients. A retrospective analysis was conducted on a series of 1405 patients undergoing unilateral or bilateral total hip or total knee arthroplasty at The Hospital for Special Surgery to determine the effect of PAD on transfusion outcomes. Eighty-three percent of patients predonated blood (1 unit to 3 units). Transfusions occurred in 82% of PAD participants and in only 50% of nondonors. The allogeneic transfusion rates were 8% for PAD participants and 50% for nondonors. Thirty-four percent to 45% of donated autologous units were discarded. Hemoglobin concentrations measured prior to surgery were inversely related to frequency of allogeneic transfusion. These data underscore the importance of hemoglobin levels in blood management planning. This information can be useful for formulating rational, cost-effective blood management guidelines.

An open-label, randomized study to compare the safety and efficacy of perioperative epoetin alfa with preoperative autologous blood donation in total joint arthroplasty

A multicenter, randomized, open-label, parallel-group study was conducted to compare the safety and efficacy of perioperative recombinant human erythropoietin (Epoetin alfa) with the safety and efficacy of preoperative autologous donation (PAD) in total joint arthroplasty. A total of 490 patients scheduled for total joint (i.e., hip or knee) surgery and having hemoglobin (Hb) levels > or = 11 to < or = 13 g/dL were randomized to receive weekly doses of subcutaneous Epoetin alfa on preoperative Days -21, -14, and -7, and on the day of surgery, or to participate in a PAD program. The mean baseline Hb level in both groups was 12.3+/-0.6 g/dL, increasing to 13.8 g/dL in the Epoetin alfa-treated group and decreasing to 11.1 g/dL in the PAD group before or on the day of surgery. In the PAD group, 156/219 (71.2%) patients were transfused with autologous blood, and 42/219 (19.2%) patients were transfused with allogeneic blood. A smaller proportion, 27/209 (12.9%) patients, in the Epoetin alfa-treated group were transfused with allogeneic blood (P = .078 compared with the PAD group). Moreover, patients in the PAD group received a total of 325 units of blood (79 allogeneic units and 246 autologous units) compared with patients in the Epoetin alfa group who received a total of 54 units of blood. The mean postoperative Hb level was 11.0 g/dL in the Epoetin alfa-treated group and 9.2 g/dL in the PAD group. Compared with the PAD arm, mean Hb levels measured preoperatively, postoperatively on Day 1, and at discharge visits were significantly greater in the Epoetin alfa-treated arm (P < .0001 ).

Acute normovolemic hemodilution

Acute normovolemic hemodilution was described to be useful as a blood conservation strategy more than 25 years ago, yet seldom is practiced today. The benefit of acute normovolemic hemodilution is perceived to be modest and the technique is not taught in anesthesia or surgery training programs. Acute normovolemic hemodilution is an autologous blood procurement strategy that is superior to the predeposit of autologous blood for several reasons: Acute normovolemic hemodilution is less costly, with an average cost of $25 per unit compared with $175 per unit predonated; and acute normovolemic hemodilution units are reinfused to patients before the patient leaves the operating room, so that the units need not be tested and there is no possibility of administrative error. Emerging clinical studies now show that acute normovolemic hemodilution is equivalent to predonated autologous blood in reducing allogeneic blood exposure in patients undergoing elective surgery.

Oxygen carriers as blood substitutes. Past, present, and future

Prospects for safe and effective blood substitutes are promising, based on clinical trial results of soluble hemoglobin solutions and emulsion of perfluorocarbins. Advantages of blood substitutes include sterilization of viral and bacterial contaminants, room temperature storage, a long shelf life, and absence of ABO and other red cell antigens. Projected arenas for their use include not only military applications but also trauma medicine and elective surgical settings, coupled with acute normovolemic hemodilution. Applications of perfluorocarbons are limited by the need for 100% FIO2. A significant challenge facing development of hemoglobin solutions is their effect on vascular tone through smooth muscle constriction. Development of second or third generation hemoglobin solutions may be necessary so that hemoglobin solutions more closely mimic cellular hemoglobin's nitric oxide binding properties. Optimizing O2 delivery to ischemic tissues and organs may lead to regulatory approval of these agents in this setting before their approval as blood substitutes.

[Benefits and risks of scheduled autologous transfusion]

Blood transfusion, like any other medical activity, requires an analysis of the risk/benefit ratio for each patient. Autologous blood transfusion does not escape this golden rule. The benefits expected of scheduled autologous transfusion consist of the reduction of the risks inherent in homologous transfusion. Those benefits are indisputable in erythrocyte alloimmunisation and viral or parasitic disease transmission. But the risks attached to such protocols have often been underestimated. The risks for the patient are still linked to the transfusion of autologous labile blood products (haemolysis, bacterial infections) or to consequences of whole blood donations (cardiovascular intolerance, increased use of transfusion, increased operative bleeding). There are also risks for the patient community insofar as autologous blood products which do not all meet the same criteria of clinical and biological validation as homologous blood products are circulated in care institutions.

Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy

BACKGROUND

The anemia associated with perioperative blood conservation has raised concerns regarding the safety of these strategies in patients with ischemic cardiovascular disease. Therefore the relationship between hematocrit level and myocardial ischemic episodes in a group of elderly patients undergoing elective noncardiac surgery was studied.

STUDY DESIGN AND METHODS

One hundred ninety patients undergoing radical prostatectomy were randomly assigned to one of three blood conservation groups: preoperative autologous blood donation, acute normovolemic hemodilution, and preoperative erythropoietin therapy with acute normovolemic hemodilution. Patients underwent ambulatory electrocardiography monitoring to evaluate for myocardial ischemia at randomization (baseline), 7 days preoperatively, throughout surgery, and for 24 hours after surgery.

RESULTS

Myocardial ischemic episodes occurred in 61 (34%) of 181 evaluable patients. Patients with hematocrit levels < 28 percent immediately after surgery were significantly (p = 0.05) more likely to have intraoperative and postoperative ECG ischemic episodes. Intraoperative ischemia and tachycardia correlated (r = 0.21, p = 0.008) with hematocrit levels. Hematocrit levels after surgery were associated with postoperative ischemia (r = 0.14, p = 0.03) and duration of myocardial ischemic episodes (r = 0.14, p = 0.04). After adjusting for other risk factors, intraoperative tachycardia episodes, hematocrit level < 28 percent immediately after surgery, and risk factors for coronary artery disease were independently associated with the likelihood of intraoperative ischemia (r = 0.36, p = 0.002, area under receiver operating characteristic curve = 0.73). Similarly, tachycardia episodes and hematocrit levels < 28 percent immediately after surgery were independently associated with ischemic episodes during the first postoperative day (r = 0.30, p = 0.004, area under receiver operating characteristic curve = 0.71).

CONCLUSION

A hematocrit level < 28 percent is independently associated with risk for myocardial ischemia during and after noncardiac surgery. Avoidance of cardiac complications may require higher transfusion thresholds, closer attention to tachycardia, or better monitoring for ischemia.

Changes in red cell transfusion practice among adult trauma victims

BACKGROUND

Recent attention concerning the adverse outcomes of blood transfusion has resulted in decreased blood product usage for nonemergency care. We hypothesized that there has also been a decrease in blood product use in the management of seriously injured adults.

METHODS

A retrospective review of institutional database records was conducted at a regional trauma center for adults admitted during 1991, 1993, and 1995. Data was analyzed for trends in amount, type, and timing of blood product use.

RESULTS

A total of 1,738 patients were assessed, with 1,605 meeting inclusion. The three patient groups were similar, including injury severity (overall mean Injury Severity Score of 23.6), mechanism (88% blunt), and survival (87%). In 1991, 54% of the patients were transfused a total of 2,341 units of packed red blood cells (mean 4.67 units/pt treated) versus 42% of patients in 1995 (p < 0.0001) who received 2,018 packed red blood cells (mean 3.57 units/patient treated, p = 0.05). A significantly higher proportion of units was transfused in the first 24 hours of care in 1995 (64%) compared with 1991 (21%, p < 0.0001). A reduction in the use of universal donor type-O blood use was also found (1.21 vs. 0.65 units/patient transfused, p < 0.0001). Despite similar admission hemoglobin concentrations (124.1 vs. 125.3, not significant), significant reductions were found in the average 24-hour (109.2 vs. 103.8, p < 0.001), lowest (96.5 vs 92.1, p < 0.01) and discharge (115.8 vs. 110.5, p < 0.001) concentrations.

CONCLUSIONS

Between 1991 and 1995 there have been significant reductions in both the number of trauma patients receiving blood products and the total number of units transfused. These findings may reflect lower or abandoned hemoglobin transfusion triggers and increased awareness of complications related to transfusion.

Preoperative autologous blood deposition in support of gynaecological repair procedures

Autologous blood transfusion was evaluated in gynaecological repair procedures including abdominal/ vaginal hysterectomy with vaginal repair, post-hysterectomy vaginal suspension and fixation, uni/bilateral salpingo-oophorectomy with vaginal colpopexy and sling procedures. A total of 247 autologous units were collected from 95 patients at the regional blood centre with 1-3 units (mean 2-6 units) deposition from each patient. One hundred and ninety of all collected units were transfused (collection/transfusion ratio = 1.3). Of these patients, 86 (90.5%) received autologous blood; 12 (13%) being transfused with 1 unit, 44 (46%) with 2 units and 30 (32%) with 3 units. Two of these patients received additional homologous blood. The average preoperative haemoglobin level was 119 g L-1 and average post-operative haemoglobin level was 105 gL-1. The post-operative Hb level was used as a retrospective indicator for the requirement for blood transfusion. The results show that overall 75% of patients had post-operative haemoglobin levels < or = 110 and 33% of patients with Hb levels < 100, respectively. These results suggest that preoperative autologous blood deposition may be appropriate in the patients undergoing reconstructive gynaecological repair procedures since there was a high rate of usage of autologous blood and low post-operative haemoglobin in a significant proportion of patients.

Preoperative autologous donation of 6 units of blood during rh-EPO treatment

PURPOSE

To determine if donation of six units of blood in three weeks is possible with self-administered subcutaneous recombinant human erythropoietin (rhEPO) injections and oral iron treatment.

METHODS

A prospective trial where a total of 32 otherwise healthy patients were phlebotomised before revision hip arthroplasty during rhEPO and oral iron treatment (ferrofumarate). Adverse events were noted and compliance was controlled. Routine laboratory tests were performed at each visit including reticulocytes and 2,3-DPG. The relative oxygen releasing capacity (RORC) and the oxygen releasing capacity (ORC) were calculated. Blood donation was postponed until the next visit if haemoglobin concentrations was < 115 g.l-1 (men) or < 105 g.l-1 (women).

RESULTS

All but two patients were able to donate six units of blood with an acceptable haemoglobin concentration on the day of operation. One serious adverse event occurred when the Hb was 119 g.l-1, compared with 149 g.l-1 before treatment. During the first two weeks before phlebotomy there was no increase in Hb, the mean nadir was reached after six phlebotomies (31 g.l-1 below pre-study level), while at operation it was 19 g.l-1 below pre-study level. There was an increase in 2,3-DPG and oxygen releasing capacity after the initiation of rhEPO therapy, before the first phlebotomy.

CONCLUSION

It is possible to donate six units of blood in a three week period before surgery during self-administered subcutaneous rhEPO treatment and oral iron therapy at a rhEPO dose of 60 U.kg-1 BW three times a week. It is suggested that rhEPO per se initiates a right-shift of the oxygen dissociation curve via an increased 2,3-DPG level, which could explain that some patients report subjective benefit of rhEPO in spite of no change in Hb concentration.

Acute normovolemic hemodilution can replace preoperative autologous blood donation as a standard of care for autologous blood procurement in radical prostatectomy

Predonation of autologous blood (PAD) is a standard of care for patients undergoing radical prostatectomy, but recent studies have shown that PAD is not cost-effective. Acute normovolemic hemodilution (ANH) is an alternative autologous blood procurement technique that is much less costly than PAD. We compared the efficacy and costs of ANH alone to ANH combined with PAD. Two hundred-fifty patients who predonated fewer than 3 units of autologous blood before radical prostatectomy underwent ANH to a target hematocrit of 28%. Perioperative hematocrit levels, transfusion outcomes and costs, and postoperative outcomes were compared for patients who predonated 0, 1, or 2 units of blood before surgery. A computer model was used to estimate the savings in red blood cells (RBC) associated with each autologous intervention. ANH alone resulted in a 21% allogeneic transfusion rate and contributed a mean net savings of 112 mL RBC in blood conservation (equivalent to 0.6 unit of blood). The addition of 1 or 2 units of PAD reduced allogeneic exposure rates to 6% or 0%, respectively. Overall, patients who predonated blood had a mean net loss of 198 mL of RBC (equivalent to 1 blood unit), due to both an absence in compensatory erythropoiesis and to the wastage of 60% of the blood units donated. Patients who underwent ANH alone had a 60% reduction in mean total transfusion costs ($103 +/- $102) compared with patients who predeposited 2 units of autologous blood in addition to ANH ($269 +/- $11, P < 0.05). We conclude that ANH can replace PAD as an autologous blood option because it is less costly and equally effective. A combination of ANH and PAD can further decrease allogeneic blood exposure, but it increases transfusion costs and wastage.

IMPLICATIONS

A patient's own blood can be obtained for use in surgery by predonation or acute normovolemic hemodilution on the day of surgery. Both blood collection techniques decrease the need for blood bank transfusions, but acute normovolemic hemodilution is less expensive and more convenient for patients.

The erythropoietic response to erythropoietin in patients with rheumatoid arthritis

We studied whether orthopedic surgical patients with rheumatoid arthritis (RA) can generate an erythropoietic response to either endogenous erythropoietin or to recombinant human erythropoietin (EPO) therapy to the same extent as patients without rheumatoid arthritis (non-RA). Seventy patients (10 RA, 60 non-RA) were entered into clinical trials of aggressive autologous blood donation before elective orthopedic surgery at one institution, randomized to receive EPO (600 U/kg, iv, 6 times over 3 weeks) or placebo. RA patients given EPO had red blood cell (RBC) production that was enhanced by 624 +/- 137 ml (mean +/- SD) as compared with 271 +/- 174 ml (p = 0.02) for RA patients given placebo treatment. Preoperative RBC volume expansion in 10 RA patients was 5.9 +/- 3.7 ml/kg as compared with 7.4 +/- 3.9 ml/kg for 60 non-RA patients (p = 0.13). RA patients can benefit to the same extent as non-RA patients from aggressive blood conservation programs that incorporate erythropoietin-modulated erythropoiesis.

The Bridgeport Hospital experience with autologous transfusion in orthopedic surgery

The transfusion records of 341 orthopedic patients who donated blood preoperatively in the years 1992 and 1993 were audited to review the transfusion practices associated with the surgical procedures. The study sample underwent 182 total knee (TKA), 123 total hip (THA) arthroplasties, and 33 laminectomies with fusion (LAM) and 3 without. Data used were age, gender, predonation hemoglobin concentration (Hbd), initial (Hbi) and final (Hbf) hemoglobin concentration, surgical procedure, surgical blood order (SBO), and estimated blood loss (EBL). We analyzed for means and associations and differences between covariates. The means of EBL (mL), transfused units, donated units, Hbi, (g/dL), Hbd, and Hbf (g/dL) for the most common procedures were: TKA--272, 1.1, 2.1, 10.4, 13.9, and 10.1; THA--951, 2.3, 2.4, 9.4, 13.8, and 9.9; and LAM--589, 1.5, 2.2, 12.0, 14.6, and 11.2. Phlebotomies for procedures with minimal blood loss, as for total knee arthroplasties, result in wastage. Autodonation under such circumstances takes patients to an unnecessary low hemoglobin concentration prior to either retransfusing the blood taken or discarding part of it. The number of preoperative autologous units donated can be reduced if predonation hemoglobin concentration is > 15 g/dL and expected blood loss is not > 2 g.

Autologous blood procurement in the surgical setting: lessons learned in the last 10 years

The percentage of blood transfused yearly that is autologous has increased substantially over the last 10 years. While autologous blood is regarded as a standard of care in many elective surgical settings, the increasing safety of allogeneic blood and the expense of autologous blood procurement have raised question regarding the appropriate roles of autologous blood in blood conservation strategies. We therefore review current activities and emerging questions that arise from this maturing arena.

Blood transfusion and deep venous thrombosis in primary total hip and knee replacement surgery: a retrospective analysis of 339 patients

Autologous blood transfusion (ABT) has become widely practiced as a useful procedure in preventing the side effects of allogeneic blood transfusion (allo-BT) and in coping with a cost-containment policy. We report on a retrospective analysis of blood support of 339 patients undergoing orthopedic elective surgery in the period 1988-1994. We observed a progressive decrease of allo-BTs (from 54.5 to 14.8% in males and from 73.7 to 15.5% in females undergoing total hip replacement), and assessed the usefulness of post-operative blood salvage in reducing the need for allo-BT when a concomitant pre-deposit program is conducted. In addition, we carefully reviewed charts in order to establish Deep Venous Thrombosis (DVT)-related morbidity, and found a surprisingly low incidence (only 3.2%) of this dreadful complication in our patient series. It is yet to be established whether anticoagulant prophylaxis and early mobilization are strongly effective in preventing DVT, or that many DVTs happen after hospital discharge and are not identified and/or reported to the orthopedic team.

Improving the efficacy of preoperative autologous blood donation in patients with low hematocrit: a randomized, double-blind, controlled trial of recombinant human erythropoietin

The effects of therapy with recombinant human erythropoietin (Epoetin alfa) on erythropoiesis, preoperative autologous blood donation, and risk of exposure to allogeneic blood were evaluated in 204 patients scheduled to undergo elective orthopedic surgery. Study protocol required patients to have a baseline hematocrit < or = 39% and surgery scheduled 25-35 days in advance. Patients were randomized to two equal groups and were seen at study centers every 3-4 days within the 21-day trial period. At each visit, phlebotomy(< or = 450 mL) was performed if the hematocrit was > or = 33%, and Epoetin alfa (600 U/kg) or placebo was administered intravenously. A total of 173 patients were assessable; 31% of placebo recipients and 20% of Epoetin alfa recipients required allogeneic transfusion (p = 0.09). Logistic regression modeling showed that the risk of allogeneic transfusion was reduced by Epoetin alfa (p = 0.025). When patients receiving > 6 units of blood (necessitating allogeneic units) were excluded from analysis, 29% of placebo recipients and 14% of Epoetin alfa recipients were exposed to allogeneic blood (p = 0.015). Epoetin alfa recipients predonated more autologous units than did placebo recipients (4.5 vs 3.0 units, respectively; p < 0.001), and their production of red blood cells increased significantly more over baseline production values (668 vs 353 mL, respectively; p < 0.05). These results demonstrate that administration of Epoetin alfa stimulates erythropoiesis, allows predonation of more units of autologous blood, and reduces the risk of exposure to allogeneic blood. Optimal dosing regimens and surgical patients most likely to benefit fro Epoetin alfa therapy must be established.

Current red blood cell transfusion practices

The appropriate use of blood transfusions remains variable among health-care institutions and patient populations. Transfusion practices are discussed in this article in relation to medical practice guidelines and utilization review. Specific transfusion practices in the settings of intensive care, orthopedic surgery, and open heart surgery are reviewed. A new, promising approach to improving transfusion outcomes is the use of transfusion algorithms. Transfusion algorithms may prove especially useful if they incorporate point-of-care testing that is both physiologic and patient-specific for transfusion decisions. Transfusion algorithms are discussed and data presented for cardiac surgical adults.

[Preoperative hemodilution by erythrocytapheresis with homologous blood saving in total hip arthroplasty]

OBJECTIVES

To compare three techniques for decreasing homologous blood requirements in total hip arthroplasty (THA), including preoperative autologous donation (PAD), preoperative acute normovolaemic haemodilution with erythrocytapheresis (erythro) and intraoperative normovolaemic haemodilution (haemo).

STUDY DESIGN

Prospective clinical trial.

PATIENTS

The study included 45 patients scheduled for THA, under general anaesthesia and operated on by the same surgeon. The patients were allocated into three groups of 15 each.

METHODS

Blood loss was assessed, during surgical procedure, by the weight of sponges and, the amount of blood collected in the suction bottles during and after surgery. The haemoglobin concentration was measured at the time of preoperative assessement (d-30), just prior to surgery (d-1), in the recovery room (d+3h), and 1, 3, and 8 days later (d8). The transfusion end-point in the three groups was to obtain a haemoglobin concentration of 100 g.L-1 from d+3h until d8. Every pack of red blood cells transfused was weighed and its haematocrit assessed to determine the accurate volume of red blood cells.

RESULTS

In the three groups haemoglobin concentration was similar from d+3h until d8. In the PAD group, no patient required homologous blood transfusion. There was no significant difference between the two other groups in the mean volume of homologous red blood cells required (308 +/- 197 mL in erythro group and 331 +/- 202 mL in the haemo group, respectively). The intraoperative blood loss was significantly higher (P = 0.001) in the erythro group: 914 +/- 305 mL vs 665 +/- 263 in the PAD group and 512 +/- 146 mL in the haemo group, respectively. There was an inverse correlation between haematocrit at d-1 and intraoperative bleeding (r = -0.7) (P = 0.0001). The distribution of the points was fitted as an exponential curve.

CONCLUSIONS

In THA, PAD is obviously the best technique to avoid homologous blood transfusion. However, when PAD is not feasible, removal of blood prior to surgery does not decrease requirements of homologous blood, as intraoperative blood loss is higher. Our results strongly question the use of major haemodilution during a surgical procedure exposing a major blood loss.

On the need for improved transfusion indicators in cardiac surgery

Guidelines for transfusion practice have had limited impact in altering physician transfusion behavior in patients undergoing cardiac operations. This may be due to a lack of consensus on the relative risks and benefits of blood in these patients who are anemic, limited access to timely data that are necessary on which to base transfusion decisions, the recognition that empiric hemoglobin/hematocrit thresholds are limited clinical indicators of the need for blood, or a combination of these. We present an overview of current transfusion and blood conservation practices in this setting, along with possible approaches to guide the decision-making process by coupling the use of transfusion algorithms with point of care testing to use more physiologic indicators of the need for blood transfusion.

Use of autologous blood in support of orthopaedic surgery using a hospital-based autologous donor programme

The use of autologous blood in support of orthopaedic surgery has been assessed for 296 patients; 150 underwent hip arthroplasty, 69 underwent knee arthroplasty, 37 underwent spinal procedures and 40 underwent miscellaneous operations. Overall, 87% of patients received no allogeneic blood and 23% of the autologous blood collected was not used. For hip and knee arthroplasty, there appears to be an increased willingness to transfuse patients when autologous blood is available, and a decreased proportion of patients receiving more than 3 units for hip arthroplasty and 2 units for knee surgery, when compared with an audit of blood use when almost all blood used was allogeneic. Wastage of autologous blood in support of spinal surgery was 66%, prompting a review of ordering practices. Assessment of avoidance of allogeneic transfusion by the standard schedule of 3 units for hip arthroplasty and 2 units for knee arthroplasty appears justified by the calculation that collection of an additional unit in each case would avoid allogeneic transfusion in 11 (5%) more patients with the unnecessary collection of 208 units.

Recombinant growth factors

Recombinant human growth factors are expected to have a significant impact on the use of allogeneic blood components. For example, subsequent to the approval of recombinant human erythropoietin, blood transfusions in renal dialysis patients declined substantially. Likewise, myeloid growth factors have reduced infections and hospital stay by promoting hematologic recovery after high dose ablative chemotherapy. The high costs of these agents mandate that their use be limited to settings where they are clinically indicated. The use of growth factors may be monitored at medical centers by hospital transfusion committees. This chapter reviews the emerging clinical guidelines for the use of hematopoietic growth factors.