Efficacy and economics of postoperative blood salvage in patients undergoing elective total hip replacement

Perioperative Blood Management, Red Cell Recovery (Cell Salvage) Practice in an Australian Tertiary Hospital: A Hospital District Clinical Audit

BACKGROUND

Data on red cell recovery (cell salvage) utilization in Australia are limited and national guidance is based on a single Australian audit conducted at a hospital that excludes cardiothoracic surgery. This clinical audit aimed to analyze the utility of red cell recovery at a tertiary health care facility which includes cardiothoracic surgery. Secondary aims of this study were to identify specific surgical procedures in which red cell recovery is most beneficial and to quantify this benefit.

METHODS

Data were collected retrospectively on all adult red cell recovery surgical cases conducted at a 2-campus health care facility over a 2-year period. Case demographic data, including surgical procedure, red blood cell return, and hematocrit levels, were collated and analyzed against national cell salvage guidelines. Average return per procedure was collated into a red cell recovery benefit analysis.

RESULTS

A total of 471 red cell recovery cases for 85 surgical procedures met inclusion criteria. Of the 7 surgical subspecialties utilizing red cell recovery, orthopedics utilized the most cases (22.9%, n = 108), followed by urology (19.1%, n = 90) and cardiothoracic surgery (18.3%, n = 86). Radical retropubic prostatectomy (11.7%), revision (7.6%), and primary (6.6%) total hip replacement were the most utilized procedures. Red cell recovery use had a 79% compliance rate with national guidelines. Vascular surgery and urology had the highest average return at 699 mL (interquartile range, 351-1127; CI, 449-852) and 654 mL (interquartile range, 363-860; CI, 465-773), respectively.

CONCLUSIONS

Overall, our center demonstrated good compliance with national red cell recovery guidelines. This audit adds to the existing data on red cell recovery practice in Australia and provides a benefit-specific surgical procedure guideline that includes cardiothoracic surgery.

Hidden blood loss and its influencing factors after percutaneous kyphoplasty surgery: A retrospective study

Percutaneous kyphoplasty (PKP) surgery is generally accepted as a minimally invasive treatment for osteoporotic vertebral compression fractures (OVCFs). However, hidden blood loss (HBL) caused by this procedure is usually disregarded. This study aimed to investigate the amount of HBL and its influencing factors after PKP surgery.A total of 160 patients were retrospectively examined from January 2014 to January 2016, and their clinical and radiological data were recorded and analyzed. Preoperative and postoperative hematocrit (Hct) and hemoglobin (Hb) levels were also documented. HBL was calculated using Gross formula. Different factors, including gender, age, bone mineral density (BMD), number of fracture levels, hypertension, diabetes mellitus, operative time, percentage of vertebral height loss, percentage of vertebral height restoration, and cement leakage, were examined. Multivariate linear regression analysis was performed to elucidate the related clinical or radiological factors of HBL.A total of 122 patients with 169 levels were eligible for inclusion in the study. The mean HBL was 279 ± 120 mL, and the postoperative Hb loss was 8.2 ± 3.9 g/L. Multivariate linear regression analysis revealed that HBL was positively associated with operative time (P = .000), percentage of vertebral height loss (P = .037), and percentage of vertebral height restoration (P = .000). By contrast, HBL was not associated with gender (P = .874), age (P = .148), BMD (P = .134), number of fracture levels (P = .079), hypertension (P = .259), diabetes mellitus (P = .495), and cement leakage (P = .975). The postoperative incidence of anemia significantly increased by 39.3% compared with that of the preoperative incidence (χ = 21.432, P = .000).For patients with OVCFs, the amount of HBL after PKP is much larger than that observed perioperatively. Operative time, percentage of vertebral height loss, and percentage of vertebral height restoration are influencing factors of HBL.

Hidden blood loss in anterior lumbar interbody fusion (ALIF) surgery

BACKGROUND

A retrospective study was performed to determine the factors affecting the total perioperative blood loss during anterior lumbar interbody fusion (ALIF). Measurements of intraoperative blood loss underestimate the true blood loss during surgery. Our research project was to examine the hidden blood loss in lumbar spine surgery. Hidden blood loss in elective knee and hip replacement surgeries range between 100% and 30%. Hidden blood loss was about 40% in posterior spine surgery.

METHODS

The factors analyzed included gender, body mass index (BMI), duration of surgery, type of surgery, aspiration, and number of fusion levels. Estimated blood loss (EBL) was obtained from the clinical records of patients as the blood collected from suctioning and the cumulative weight of the saturated sponges. Actual blood loss (ABL) was calculated from the estimated blood volume and hemoglobin level of patients. Hidden blood loss was calculated as the difference between ABL and EBL.

RESULTS

Seventy-eight consecutive patients who underwent ALIF were reviewed. The average values (mean±SD) for EBL and ABL were 700.1±562.3mL and 1150.6±770.0mL, respectively (P=0.001, Student's t-test). The hidden blood loss averaged 39.2% of the ABL. According to linear regression analysis, surgical duration, type of surgery, and the inclusion of the L4/5 level were independent factors contributing to the ABL (P<0.05), whereas BMI and gender did not correlate with ABL or EBL.

CONCLUSIONS

ALIF is associated with substantial perioperative hidden blood loss. Length of surgery, type of surgery, and the inclusion of L4/5 in the procedure are significant risk factors for increased blood loss.

LEVEL OF EVIDENCE

Level IV: retrospective or historical series.

Effects of the Sangvia blood collection system on patients undergoing elective hip surgery

We have conducted a randomized controlled study where 164 patients were randomized to receive autologous salvaged blood collected by Sangvia™ Blood Salvage System or allogeneic red cell concentrates if transfusion was indicated by clinical judgement. The study was powered to detect if transfusion of autologous blood reduced the occurrence of postoperative infections. We found no statistical significant difference in postoperative infection rate between the groups, but this may be due to the fact that postoperative infections were diagnosed in only five patients. Increased C-reactive protein concentrations slightly above level of significance indicate that autologous blood transfusions stimulate the patient's immune system. However, there was no indication of increased transfusion reaction rate, including febrile reactions, in the autologous group. Transfusion of autologous blood did not reduce the use of allogeneic red cell concentrates. The mean use of allogeneic red cell concentrates was 0.93 units (both groups combined), indicating that the transfusion policy may have been too liberal. There was a highly significant inverse correlation between pre-operative haemoglobin concentration and transfusion of allogeneic blood. In a patient population with a low frequency of postoperative infection, a larger study is needed to clarify if autologous salvaged blood protects against postoperative infections.

The increased total cost associated with post-operative drains in total hip and knee arthroplasty

In a consecutive series of 536 unilateral primary total hip arthroplasties (THAs) and 598 unilateral primary total knee arthroplasties (TKAs), the use of a post-operative drain was associated with $538 additional cost per THA, and $455 for TKA. The use of a drain increased hospital length of stay (LOS) for THA, but not for TKA. In both groups, the use of a drain increased estimated blood loss (EBL) and increased the amount of allogeneic blood transfused. Over the 10-week period, drain use was associated with a total cost of $432,972 for our institution. Data from this study would favor a selective approach to the use of drains in primary joint arthroplasties.

Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial

BACKGROUND

Postoperatively shed blood salvage is commonly used to reduce allogenic blood transfusion in patients undergoing total hip (THA) and knee arthroplasty (TKA). Autologous blood retransfusion is not devoid of risk. We hypothesized that adding tranexamic acid (TXA) to a restrictive blood transfusion protocol would reduce the need for postoperative autologous blood retransfusion in primary knee and hip arthroplasty.

STUDY DESIGN AND METHODS

Ninety-eight adult patients undergoing primary THA or TKA were randomly assigned to receive an intraoperative intravenous loading dose of 1.0 g of TXA followed by another 1.0-g dose 3 hours later (TXA group) or a matching volume 0.9% saline placebo (control group). A postoperatively shed autologous blood recovery system was used in all patients and the minimum reinfusion volume set at 250 mL. Red blood cells were transfused if hemoglobin level was less than 8 or if 8 to 10 g/dL with symptoms of anemia.

RESULTS

The proportion of patients receiving autologous blood reinfusion was significantly lower in the TXA group (5/49) compared to placebo (42/49) with an absolute difference of -75.5% (adjusted relative risk, 0.005), and none of the patients in the TXA group received more than 400 mL retransfused. Median total external blood loss during the first 24 hours was lower in the TXA group, 320 mL (range, 80-930 mL), compared to 970 mL (range, 100-2600 mL) in the placebo group (p < 0.001). There were no significant differences in homologous blood transfusions and hematologic variables between groups. Treatment differences were consistent by size and significance when the analysis was repeated separately in patients undergoing TKA or THA.

CONCLUSION

Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary.

[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.