Postoperative blood salvage in hip and knee arthroplasty. A prospective study on cost effectiveness in 161 patients

Does tourniquet use decrease blood loss following primary total knee arthroplasty in Jehovah's Witness patients?

OBJECTIVES

This study aims to investigate the use of multiple blood management strategies and the effect of tourniquet on the estimated blood loss (EBL) in Jehovah's Witness (JW) patients who underwent primary total knee arthroplasty (TKA).

PATIENTS AND METHODS

Twenty-two self-reported JW patients (9 males, 13 females; mean age 66.8±8.6 years; range, 51 to 83 years) who underwent primary TKA between January 2014 and January 2020 in our institution were retrospectively reviewed. A standard blood management protocol that consisted of hypotensive anesthesia, local and systemic administration of tranexamic acid (TXA) and intraoperative cell salvage was applied to all patients. Patients were divided into two groups: with (n=11) and without (n=11) tourniquet use. The EBL was calculated according to Meunier's formula. Hemoglobin (Hgb), hematocrit (Hct), and EBL on the first and third postoperative days were compared statistically.

RESULTS

There was no significant difference between groups regarding postoperative Hgb (p=0.801 and p=0.767), Hct (p=0.617 and p=0.895), Hgb decline (p=0.311 and p=0.822), and EBL (p=0.067 and p=0.284) at first and third postoperative days. None of the patients required blood transfusion. No wound complication or symptomatic deep vein thrombosis was seen during the hospital stay.

CONCLUSION

Combined use of hypotensive anesthesia, intravenous administration of TXA, intraoperative periarticular injection, and cell salvage seem to be sufficient in controlling the blood loss in JW patients during TKA. Additional tourniquet use may not further decrease the EBL.

Use of Intravenous Tranexamic Acid to Reduce Allogeneic Blood Transfusion in Total Hip and Knee Arthroplasty: A Meta-analysis

Total hip or knee arthroplasty is associated with significant blood loss. Techniques such as the use of antifibrinolytics or desmopressin, or normovolaemic haemodilution have been used to reduce the need for allogeneic blood transfusion. Tranexamic acid has been used to reduce blood loss and transfusion requirement for total hip and knee arthroplasty, with variable results. This meta-analysis aims to evaluate whether intravenous tranexamic acid, when compared with placebo, reduces blood loss and transfusion requirement in total hip and knee joint replacement surgery and whether it might increase the risk of thromboembolic complications. The literature search was based on MEDLINE, EMBASE, Cochrane Controlled Trials Register, and information from the pharmaceutical company that produces tranexamic acid (Pharmacia-Upjohn). We identified 15 clinical trials and 12 were considered suitable for detailed data extraction. Tranexamic acid reduces the proportion of patients requiring allogeneic blood transfusion (OR 0.16, 95% CI: 0.09–0.26), total amount of blood loss (WMD 460 ml, 95% CI: 274–626 ml), and the total number of units of allogeneic blood transfused (WMD 0.85 unit, 95% CI: 0.36–1.33). Tranexamic acid does not increase the risk of thromboemobolic complications such as deep vein thrombosis, pulmonary embolism, thrombotic cerebral vascular accident, or myocardial infarction (OR 0.98, 95% CI: 0.45–2.12). Intravenous tranexamic acid appears effective and safe in reducing allogeneic blood transfusion and blood loss in total hip and knee arthroplasty.

Post-operative retransfusion of unwashed filtered shed blood reduces allogenic blood demand in hip hemiarthroplasty in traumatic femoral neck fractures-a prospective randomized trial

PURPOSE

Patients who undergo hip hemiarthroplasty (HHA) due to traumatic femoral neck fracture frequently require red blood cell (RBC) transfusion. Although post-operative autologous blood transfusion (ABT) is well established in elective arthroplasty, its role in trauma patients remains unclear.

METHODS

Two hundred twenty-nine patients with a traumatic femoral neck fracture that underwent HHA at our level-I trauma centre between 2005 and 2009 were prospectively randomized to a high-vacuum drainage or an ABT device. In this single-institution analysis, the number of RBC units as well as the amount of retransfused shed blood were recorded and compared according to study groups. Additionally, the significance of confounding factors for allogenic blood demand such as age, gender, pre-operative Hb level, surgical approach, type of prosthesis and amount of intra-operative RBC units were evaluated using multivariate analysis.

RESULTS

One hundred thirty-five patients were randomized in the high-vacuum group while 94 patients received an ABT device. Intention to treat analysis revealed no significant difference in post-operative RBC demand (ABT: 0.87 RBC, high-vacuum drainage: 1.01 RBC; P = 0.374). However, patients that actually received retransfusion (N = 35) had a reduced post-operative RBC demand (0.49 RBC units, P = 0.014).

CONCLUSION

While only one third of trauma patients treated with an ABT device during HHA actually receive retransfusion, retransfused patients seem to significantly benefit from this treatment as reflected by a reduced pos-toperative RBC demand.

Preoperative erythropoietin alpha reduces postoperative transfusions in THA and TKA but may not be cost-effective

BACKGROUND

Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs can be justified when weighed against the transfusion reductions achieved in patients who receive the drug.

QUESTIONS/PURPOSES

The purpose of this study is to investigate (1) efficacy of preoperative EPO in reducing postoperative transfusions in TKA and THA; (2) whether patients treated with EPO have reduced length of stay or a different discharge disposition; and (3) whether EPO use reduces overall blood management costs.

METHODS

Patients undergoing primary THA or TKA over a 10-month period with preoperative hemoglobin<13 g/dL were recommended to be treated preoperatively with EPO. During that time, 80 of 286 (28%) patients met that inclusion criterion and the treating team recommended EPO to all of them; of that group, 24 (30%) opted to take EPO and 56 (70%) opted not to. Patients receiving at least one dose of EPO and those not receiving EPO were compared in terms of transfusion frequency, length of stay and discharge disposition, and overall blood management costs. Demographics, preoperative hemoglobin, and operative blood loss for both groups were similar (p>0.05). No transfusion triggers were used; rather, patients with postoperative hemoglobin<10 mg/dL and who were symptomatic despite fluid boluses were transfused. The clinician responsible for transfusing symptomatic patients was blinded to the patient's EPO treatment status. Costs were defined as direct costs paid or incurred by our institution for EPO, allogeneic blood, and variable costs associated with patient care after THA/TKA. A decision-tree cost analysis was performed using the collected clinical data and cost data collected from our institution; the analysis considered total associated blood management cost for an EPO and a non-EPO strategy with sensitivity analysis of key cost variables.

RESULTS

The proportion of patients receiving transfusions was lower in patients who received EPO than in patients who did not (0% [zero of 24] versus 41% [23 of 56]; p<0.001). The mean length of inpatient hospital stay (EPO: 3.0±0.4 versus control: 3.3±0.8 days, p=0.77) and discharge disposition also was not different between the groups. The cost analysis demonstrated that the EPO strategy was more costly compared with no EPO (USD 2632 versus USD 2284) and its cost would need to be less than USD 225/dose for this to change.

CONCLUSIONS

EPO reduced the need for postoperative transfusions in high-risk patients undergoing THA and TKA; however, it was not found to be cost-effective in our model. Our model could not consider relatively rare complications of blood transfusions, including disease transmission, deep periprosthetic infections, and transfusion reactions, but if surgeons or patients value avoiding these potential but rare factors highly, this could reasonably influence the decision of whether to use EPO despite our findings that it was not cost-effective.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hemostatic matrix effects on blood loss after total knee arthroplasty: A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) can result in major postoperative blood loss which can impact on the recovery and rehabilitation of patients. It also requires expensive transfusions. The purpose of the study was to investigate whether a hemostatic matrix, composed of cross-linked gelatin and a thrombin solution, would reduce blood loss in patients following TKA.

MATERIALS AND METHODS

THIS WAS A PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY (TRIAL REGISTRATION: Hospital S. Salvatore L'Aquila ADJ00843) conducted in 93 patients. Criteria for participation were unilateral TKA for osteoarthritis, and a preoperative hemoglobin level >13 g/dL. The outcomes measured were postoperative hemoglobin and hematocrit levels measured at 24h, 72 h, and 7 days. The mean total postoperative blood loss was calculated from drainage volume, patient blood volume, hematocrit, and red blood cell volume. In addition, the drain output within 24 h following surgery and any transfusion requirements were determined.

RESULTS

Hemostatic matrix-treated patients (n = 51) showed significant reductions in calculated postoperative blood loss of 32.3% and 28.7% versus control in men and women, respectively (P < 0.01). Postoperative blood loss after 24 h in drain was significantly less with the hemostatic matrix versus control, as were decreases in hemoglobin levels 7 days post-surgery (each P < 0.01). Three patients in the control group required blood transfusion, whereas no blood transfusions were necessary in the hemostatic matrix group.

CONCLUSION

The use of a hemostatic matrix provides a safe and effective means to reduce blood loss and blood transfusion requirements in TKA.

Blood transfusion and cytokines' changes in total knee replacement

INTRODUCTION

The aim of this prospective comparative study was to evaluate the serum levels of different cytokines and the frequency of adverse reactions and wound infections in patients who underwent total knee replacement (TKR) and were not transfused or received either allogeneic blood transfusion or postoperative auto-transfusion (PAT) with unwashed shed blood.

MATERIALS AND METHODS

A total of 248 patients were categorized into three groups; in Group 0 (n 85) patients received no blood transfusion, in Group 1 (n 92) patients received PAT and in Group 2 (n 71) patients received allogeneic blood transfusion. Patient's demographic and clinical data including age, gender, body mass index, preoperative haemoglobin value, adverse reactions and complications were documented. The serum levels of IL-1b, IL-6, IL-8, IL-10 and TNF were measured preoperatively, and on the first, third and fifth postoperative day. A statistical analysis of the results was performed.

RESULTS

A significant elevation of cytokine values were observed during the first five postoperative days in patients who received blood transfusion after TKR. Adverse reactions (chills and pyrexia) were also more common in patients who received blood transfusion, whereas superficial infections were more common in patients who received allogeneic blood transfusion.

CONCLUSION

The immunological status-as expressed by the measured cytokine levels-is altered in patients receiving blood transfusion compared to patients receiving no blood transfusion during the first five postoperative days. PAT is preferable to allogeneic blood transfusion in terms of the rate of adverse reactions and superficial wound infections.

The effect of surgeon volume on the need for transfusion following primary unilateral hip and knee arthroplasty

INTRODUCTION

we reviewed transfusion practice following primary hip and knee arthroplasty with emphasis on the relationship between surgeon volume and the need for transfusion.

MATERIALS/METHODS

review of a consecutive series of 508 primary, elective, unilateral arthroplasties (248 THR/260 TKR) performed over a 12-month period. Data were analysed to determine the overall rate of transfusion and the details of any such transfusion. Secondarily, multivariate regression was performed to determine the effects of surgeon volume and other recorded variables upon the need for transfusion. For the purpose of analysis we classified surgeons doing more than 52 arthroplasties a year as "high volume" and surgeons performing less than this number as "low volume".

RESULTS

transfusion rates were 10% and 7% following THR and TKR. Multivariate analysis demonstrated that surgeon volume (<52 operations/yr vs. >52 operations/yr) and preoperative Hb<12g/dl were the only significant determinants of a need for postoperative transfusion (p<0.01). High volume and low volume surgeons transfused 5% vs. 17%, respectively (RR=3.3 (95%CI 1.5-9.1) p=0.003) following THR and 4% vs. 13% (RR=3.6 (95%CI 1.4-9.3) p=0.006) following TKR.

DISCUSSION AND CONCLUSION

High volume surgeons have significantly lower transfusion rates when compared to nationally accepted figures.

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.

A prospective randomised controlled trial of autologous retransfusion in total knee replacement

We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood. Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.

Post-operative blood salvage with autologous retransfusion in primary total hip replacement

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.

Autologous blood transfusion following total knee arthroplasty: is it always necessary?

A retrospective study of 85 patients undergoing primary total knee replacement (TKR), who also received autologous blood transfusion (ABT) to compensate for the perioperative blood loss. In our series 16.4% of the patients needed allogenic blood transfusion. Of the remaining 83.4% only 49.5% received autologous transfusion. Autologous transfusion was withheld in 34.1% of cases either because the blood volume was inadequate or because the collection time exceeded the recommended time limit. The mean haemoglobin (Hb) level with or without autologous transfusion was 10 g, raising the question of the necessity of using autologous transfusion in primary total TKR.

A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty

The routine use of surgical drains in total hip arthroplasty remains controversial. They have not been shown to decrease the rate of wound infection significantly and can provide a retrograde route for it. Their use does not reduce the size or incidence of post-operative wound haematomas. This prospective, randomised study was designed to evaluate the role of drains in routine total hip arthroplasty. We investigated 552 patients (577 hips) undergoing unilateral or bilateral total hip arthroplasty who had been randomised to either having a drain for 24 hours or not having a drain. All patients followed standardised pre-, intra-, and post-operative regimes and were independently assessed using the Harris hip score before operation and at six, 18 and 36 months follow-up. The rate of superficial and deep infection was 2.9% and 0.4%, respectively, in the drained group and 4.8% and 0.7%, respectively in the undrained group. One patient in the undrained group had a haematoma which did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures (p < 0.042). The use of a drain did not influence the post-operative levels of haemoglobin, the revision rates, Harris hip scores, the length of hospital stay or the incidence of thromboembolism. We conclude that drains provide no clear advantage at total hip arthroplasty, represent an additional cost, and expose patients to a higher risk of transfusion.

Blood salvage in total hip and knee arthroplasty in a community hospital: a retrospective study

PURPOSES

To assess the results of postoperative and intra-operative blood salvage in patients undergoing total knee and hip arthroplasty, respectively, and to determine if both methods of blood salvage reduce allogeneic transfusion.

METHODS

Of 229 patients who attempted blood salvage, 114 of 152 patients who underwent total knee arthroplasty received the salvaged blood postoperatively, 35 of 77 patients who underwent total hip arthroplasty received the salvaged blood intra-operatively. Various data were collected to assess whether certain factors resulted in autologous and/or allogeneic blood transfusions.

RESULTS

Patients that received postoperative salvaged blood after total knee arthroplasty generally had higher postoperative levels of haemoglobin and haematocrit compared to those who did not. Patients with autologous blood transfusion following cemented knee surgery were less likely to require allogeneic blood transfusion. For hip arthroplasty patients, postoperative levels of haemoglobin and haematocrit were similar in both groups who received and did not receive salvaged blood. Lower preoperative haemoglobin and haematocrit levels correlated with a greater likelihood of autologous and/or allogeneic blood transfusion for both knee and hip arthroplasty patients.

CONCLUSIONS

Although total knee arthroplasty patients who received salvaged blood had higher haemoglobin levels on the first postoperative day, the receipt of salvaged blood did not significantly reduce the incidence of allogeneic blood transfusion, because salvaged blood was a kind of blood loss. However, reinfusion of salvaged blood may reduce the number of units of allogeneic blood used. Given the short supply of allogeneic blood and its risks of transmitting disease, intra-operative and postoperative blood salvage carries clear advantages.

Composition of the blood sampled from surgical drainage after joint arthroplasty: quality of return

BACKGROUND

The quality of blood obtained with a device for postoperative blood drainage and autotransfusion (Bellovac-ABT, Astra Tech AB) was investigated in 50 patients who underwent total hip replacement (THR) or total knee replacement (TKR) surgeries.

STUDY DESIGN AND METHODS

The Bellovac-ABT drainage set was inserted and blood collection began after skin closure (THR) or 15 minutes after tourniquet deflation (TKR). A collecting bag stayed in place for less than 6 hours. The product was then returned after sedimentation and discard of supernatant, without anticoagulants.

RESULTS

Blood returned with the Bellovac-ABT had optimal hemoglobin levels and red blood cell (RBC) counts; the low platelet count reduced the risk of disseminated intravascular coagulation. Inertia of materials maintained acceptable values of C-reactive protein, whereas cytokines and complement split products rose rapidly. Higher concentrations of adenosine triphosphate and 2,3-diphosphoglycerate than in circulating blood suggested a normal RBC metabolism. No adverse reactions were observed in any participants.

CONCLUSION

Because of its simplicity and safety, the Bellovac-ABT autologous blood transfusion system is recommended in THR or TKR without joint infection or malignancy.

Economic evaluation in total hip arthroplasty: analysis and review of the literature

We performed a bibliographic search of MEDLINE databases from January 1966 to July 2002 to identify English language articles that contained either "cost" or "economic" in combination with "total hip arthroplasty" (THA) in the abstract or title. Each study was then critically reviewed for content, technique, and adherence to established healthcare economic principles. Only 81 of the 153 studies retrieved contained actual economic data. Only 6% of studies adhered to established criteria for a comprehensive health care economic analysis. Although the number of publications regarding economic evaluation of THA is on the rise, the methodologic quality of many of these studies remains inadequate. Future studies should employ sound healthcare economic techniques to properly evaluate and assess the true social and economic value of THA.

Reduction of blood transfusion rates in unilateral total knee arthroplasty by the introduction of a simple blood transfusion protocol

We prospectively studied blood transfusion practices within a single institution before and after the introduction of a blood transfusion protocol in consecutive patients undergoing unilateral total knee arthroplasty. Data were collected on 393 patients (group I) prior to and 295 patients (group II) after the introduction of the protocol. Following the introduction of the protocol, patients with preoperative haemoglobin of less than 11 g/dl were cross-matched prior to surgery. The criterion for postoperative transfusion was postoperative haemoglobin of less than 8.5 g/dl or a symptomatic patient with haemoglobin of greater than 8.5 g/dl. This change in practice reduced the transfusion rates from 31% in group I to 11.9% in group II. It reduced the non-utilisation of blood from 64 to 1%. There were no adverse outcomes related to the introduction of the protocol.

Can knee position save blood following total knee replacement?

Previous research showed knee flexion at 70 degrees for 6 h following total knee replacements (TKR) reduced wound drainage by 30%. However, wound drainage may not represent total blood loss and obstruction of the drain in flexion or the relative elevation of the knee could have caused the reduction in drainage. We wished to confirm that this simple, cheap method not only reduced wound drainage but also total haemoglobin loss and determine what part elevation or drain obstruction may play. Sixty consecutive TKR patients were randomly allocated to three groups. Group 1-knee extended and level with bed. Group 2-leg elevated 35 degrees at the hip with knee flexed to 70 degrees for 6 h post-operatively. Group 3-leg elevated 35 degrees at the hip with knee extended for 6 h post-operatively. We assessed wound drainage over 48 h, calculated haemoglobin loss, total blood transfusion, pain, arc of motion, swelling, length of hospital stay and complications. We found knee flexion and knee elevation in extension reduced haemoglobin loss by 25%. Compromise to tissue oxygenation has been reported with knee flexion. We recommend elevation of the leg at 35 degrees from the hip with the knee extended. This offers a simple, safe and effective way to reduce total blood loss by 25%.

Intraoperative autotransfusion in hip arthroplasty

Two groups of patients having primary or revision total hip replacement were studied during a period of 11 months. The first group of 40 consecutive patients consented to have whole blood collected coincident with acute normovolemic hemodilution. An inventory of autologous red blood cells, plasma, and platelets was prepared in the operating room as a preliminary to surgery. Subsequently, the same supplies and equipment were used for autotransfusion intraoperatively. In a case-control study, another 40 patients having total hip replacements were matched for age, gender, and weight. The second group of patients refused hemodilution and received autotransfusion alone. The perioperative transfusion requirements of the two groups were compared. The total blood product donor exposure rate of the first group was 1/4 of the controls (0.6 and 2.4 donor units per patient, respectively). The average length of stay in the hospital after surgery for the first group was shortened significantly (6.2 versus 8.4 days), possibly from less immunogenic insult associated with increased transfusions of autologous blood products. Hemodilution, followed by autotransfusion, was cost effective in primary and revision total hip replacements, autotransfusion alone was cost effective only in revision arthroplasty.

Relative cost of autologous red cell salvage versus allogeneic red cell transfusion during abdominal aortic aneurysm repair

The costs of washed autologous red cell concentrate obtained by intraoperative red cell salvage were compared to the costs of allogeneic packed red cell transfusion during 110 consecutive abdominal aortic aneurysm repairs. The mean volume of scavenged blood during elective procedures was 1350 ml (range 350 to 6675 ml, n = 90) and emergency procedures 2750 ml (range 750 to 9400 ml, n = 20). The mean volume of processed (washed) blood returned during elective repairs was 759 ml (range 150 to 2900 ml, n = 51) and emergency repairs 1117 ml (range 0 to 4100 ml, n = 20). During elective repairs, the cost of routine autologous red cell salvage ($151 per 285 ml unit) was only slightly greater than the estimated cost of cross-matched, leucocyte-reduced, allogeneic blood ($143 per 285 ml unit). During emergency repairs, washed autologous red cells ($83 per 285 ml unit) were less expensive than allogeneic packed red cells. These findings indicate that, compared with the use of allogeneic packed red cells, red cell salvage during emergency abdominal aortic aneurysm repair can be justified on an economic basis alone, and that routine red cell salvage during elective repair can achieve the benefits of autologous blood at little extra cost to the community.

Cost-effectiveness analysis and the selection of blood products

A new generation of blood components and transfusion modalities aimed at further reducing real or hypothetical risks threatening the blood supply is available. Since the risk of infection with transfusion-transmitted viruses is already very low, many of these new interventions provide a minimal health benefit at a very high cost. It is even possible that risks inherent to the new technologies themselves could surpass the current risk of transfusion-transmitted viruses. For some of the new blood components, such as leukoreduced products, the poor cost-effectiveness projections may be substantially improved if the purported health benefits are eventually proved in appropriate randomized, controlled clinical trials. Meanwhile, cost-effectiveness analyses show that allocating more resources to improve the safety of donated blood may actually decrease the overall transfusion safety by subtracting resources from other areas of the health care system, so a realignment of costs with health benefits seems necessary.

The cost-effectiveness of postoperative recovery of RBCs in preventing transfusion-associated virus transmission after joint arthroplasty

BACKGROUND

The return of joint drainage after hip and knee arthroplasty is a widely used but expensive blood-conservation technique.

STUDY DESIGN AND METHODS

A Markov decision analysis model was used to evaluate the cost-effectiveness of postoperative RBC recovery in preventing viral complications of allogeneic transfusion.

RESULTS

In the baseline analysis, using an RBC-recovery device saves 5 quality-adjusted minutes of longevity at an average incremental cost of $53. This corresponds to $5.7 million per quality-adjusted life year. This figure was most sensitive to the direct cost differences of allogeneic versus recovered RBCs and to the volume of RBCs recovered per device. Such devices would save health care resources if they cost less than $73 or if they were applied only in cases where joint drainage was between 600 and 1100 mL.

CONCLUSION

For most clinical situations, postarthroplasty RBC recovery does not appear to be as cost-effective as most other medical interventions. Clinical attention should be directed toward developing protocols for the preferential use of postoperative RBC-recovery devices in situations where they provide the greatest benefit.