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Blood Management
Key Points
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Blood transfusions remain relatively common following both primary and revision hip arthroplasty procedures and are associated with significant risks.
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Comprehensive blood management strategies reduce the need for blood transfusions; thus, they should be considered an integral part of contemporary orthopedic practice.
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Preoperative measures include the evaluation and treatment of chronic anemia.
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Intraoperative techniques include the routine use of antifibrinolytic medications such as tranexamic acid, which may be administered either topically or systemically.
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Postoperatively, the most important intervention remains adherence to existing well-studied restrictive transfusion thresholds. Red cell transfusion is almost never indicated until the hemoglobin level is less than 8 g/dL for patients undergoing orthopedic surgery.
Introduction
Primary and revision hip replacement surgery are often associated with significant blood loss and risk of allogeneic transfusion. Although this risk has changed dramatically over the past 15 years, a certain minimum amount of blood loss will always be due to the nature of hip replacement surgery. Furthermore, total hip arthroplasty (THA) procedures are often performed on geriatric patients whose vessels are fragile and who may be less tolerant of acute blood loss anemia. Blood loss from primary total hip replacement surgery has been reported to range from 500 to 2000 mL, with an average drop in hemoglobin of 4.0 ± 1.5 g/dL reported. Blood loss of this magnitude indicates that careful planning is required to decrease transfusion risk.
Basic Science
In a multicenter study, Bierbaum and associates described blood use in 9482 patients undergoing total joint replacement surgery. They found greater blood loss in patients who were in the revision joint replacement category. A total of 5741 patients (61%) had predonated autologous blood, of which 45% (4464 units) was not used and was discarded. In this study, patients undergoing primary hip or knee arthroplasty had the greatest number of wasted units. Also noted were 503 patients (9%) who predonated blood and received their autologous units yet still required an additional allogeneic blood transfusion. Patients with a preoperative hemoglobin of 13 g/dL or less and those undergoing revision total joint replacement had the highest allogeneic transfusion risk. The Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study of 3945 patients showed similar results. In this study, 75% of patients received transfusions, 35% received only autologous blood, and 26% received only allogeneic blood. In the European study, allogeneic transfusions were associated with an increased wound infection rate of 4.2% versus 1%. Findings in both of these studies showed that patients requiring allogeneic transfusion had a longer hospital stay. Both studies also found that preoperative hemoglobin levels less than 13 g/dL increased allogeneic transfusion risk by about four times.
Finally, in a more recent study, Yoshihara and Yoneoka described the national trends in blood transfusion following lower extremity arthroplasty surgeries performed between 2000 and 2009. Despite many efforts to reduce the overall transfusion rate, it remained relatively stable over that time frame, with slightly increased rates of allogeneic blood transfusion offset by lower rates of autologous transfusion. The overall transfusion rate for patients undergoing primary THA, including both allogeneic and autologous, ranged from approximately 20% to 25% during that study period.
It is critically important to recognize the risks associated with allogeneic red cell transfusion. Although the general public has often focused on the risks of viral disease transmission, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV), much more common are the risks of transfusion-associated circulatory overload and transfusion-related acute lung injury ( Tables 21.1 and 21.2 ). Furthermore, patients receiving allogeneic transfusions seem to be more susceptible to periprosthetic joint infection secondary to immune modulation, are known to require greater hospital length of stay, and incur significantly increased overall costs of care. Given the relative frequency of allogeneic red cell transfusions after hip arthroplasty procedures and the many negative effects associated with this intervention, comprehensive blood management strategies aimed at reducing the need for transfusions should be considered an integral part of contemporary orthopedic practice.
TABLE 21.1
Approximate Risk Per Unit Transfusion of Red Blood Cells (RBCs)
Adapted from Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. Red blood cell transfusion thresholds and storage. JAMA . 2016;316(19):2025–2035.
| Adverse Event | Risk Per Unit RBC Transfusion |
|---|---|
| Febrile reaction | 1 : 60 |
| Transfusion-associated circulatory overload (TACO) | 1 : 100 |
| Allergic reaction | 1 : 250 |
| Transfusion related acute lung injury (TRALI) | 1 : 12,000 |
| Hepatitis C infection | 1 : 1,149,000 |
| Hepatitis B infection | 1 : 1,208,000 to 1 : 843,000 |
| HIV infection | 1 : 1,467,000 |
| Fatal hemolysis | 1 : 1,972,000 |
TABLE 21.2
Summary of Interventions to Reduce the Risk of Postoperative Blood Transfusion
| Highly Effective | Moderately Effective | Minimally Effective |
|---|---|---|
|
Combined use of
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Individual use of
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Current Controversies and Future Directions
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