Blood management in the 21st century: The importance of teamwork
The variable costs of interventions such as joint replacement are increasingly important to control with our evolving health care environment. Estimates predict an exponential increase in the demand for total joint arthroplasty during the next 10 to 20 years.
The use of packed red blood cells (PRBCs) to treat perioperative anemia at the time of surgery is one such variable. The cost of blood management is far-reaching and it is apparent that a 21st century approach is needed to minimize these costs while we optimize our patient outcomes.
Impact of transfusion
The transfusion of PRBCs to the total joint arthroplasty (TJA) patient has tremendous impact on our health care systems. The direct cost of transfusion of PRBCs within the University of Pittsburgh Medical Center (UPMC) hospitals is currently estimated at $750,000 per year in the care of patients undergoing joint arthroplasty. The true cost of transfusion is much greater due to the risks incurred with the use of red blood cell transfusion. Although allogeneic transfusion carries a risk of disease transmission, these risks are much less common and do not have a significant impact on our patient outcomes. Of greater concern and more common is a well documented increased risk of infections, wound complications, transfusion reactions, and an extended length of stay. These complications are not necessarily negated with an autologous donation program.
Brian R. Hamlin
The routine use of preoperative donation of autologous red cells has fallen out of favor. Although this was popular — and came into vogue due to concern about blood borne pathogen transmission in the 20th century — it is costly and wasteful. Probably of most import is the realization that placing patients in an anemic state prior to a surgical stress was not well founded or logical.
Another common methodology that has been proven to lack validation is a transfusion trigger of 10g/dl. This trigger was set based on tradition and perceived risk of cardiac complications. Most patients can tolerate hemoglobin much less than 10g/dl without effecting outcomes.
A more realistic trigger
By using fairly strict criteria for transfusion the percentage of patients requiring PRBCs can be greatly diminished. Our Orthopaedic Program at Magee Women’s Hospital of UPMC had a transfusion rate of 10% using old criteria. The transfusion trigger has been reset to 8g/dl and symptoms of hypovolemia are first treated with fluid support. Using this approach the transfusion rate has been reduced to 3% within our joint replacement program. Despite using these lower trigger values some patients will still require transfusion. Several variables influence the risk of transfusion including preoperative hemoglobin (Hgb), blood loss during surgery, length of surgery, as well as continued blood loss after surgery. Affecting these variables can decrease the risk of transfusion as well as lessen the overall degree of perioperative anemia and its effects on our patients.
Optimization for surgery
Patients who come to surgery anemic (men with Hgb less than 13g/dl; women less than 12g/dl) are at a much higher risk of requiring transfusion. We have found that almost 25% of our patients come to surgery in this state. An algorithmic approach can be used for the proper workup and treatment of anemia. These interventions can be directed by a primary care physician or within the framework of a health care system or hospital. With proper timing and attention to detail a system can be put in place to correct most preoperative anemia without delaying elective surgical scheduling. Epoetin alpha has been used in the past to treat anemia but has come under scrutiny due to its risk profile (potential cancer and venous thromboembolic risk), cost and variable insurance coverage. Intravenous iron therapy is now being used to treat many patients with preoperative anemia due to iron deficiency. Newer preparations have been shown to be more tolerant by patients and it is not as cost prohibitive as epoetin.
Several methods can be of benefit to try to reduce blood loss during surgery. Hypotensive general anesthesia and regional anesthesia can aid in reducing intraoperative blood loss. Cell salvage can be of benefit if excessive blood loss, such as in revision hip arthroplasty is to be expected, but is not helpful in routine primary arthroplasty. Postoperative cell salvage can also be used but it’s true effectiveness in reducing need for transfusion is not well established.
A variety of intraoperative devices and agents have been developed to assist in coagulation or control of bleeding tissues. Unfortunately, these can easily cost $500 to $1,000 per case. The topical agents that are fibrin-based have shown to be effective but are hard to justify for routine use do to their great cost.
New use of an older drug
Tranexamic acid (TXA) is an antifibrinolytic agent that has traditionally been used in surgical cases where massive blood loss and coagulopathy is common. Several studies have now documented effectiveness with TXA in primary and revision arthroplasty in reducing blood loss and transfusion rates. Although there is a concern of causing venous thromboembolism (VTE) no orthopedic studies to date have shown any increased risk. Traditionally it has been used in an intravenous manner, but it has also been effective when used topically for reducing blood loss and transfusion risk with minimal absorption in the blood stream. This may be a more safe use of this agent for the portended risk of VTE. Compared to other measures the cost of TXA is markedly less than other topical (fibrin-based) agents currently being used on the market. Several total joint centers around the United States are now using TXA intravenously as standard protocol.
Rethinking VTE prophylaxis
One potential source of blood loss may be iatrogenic due to a trend for overzealous anticoagulation with chemical prophylaxis. Despite these aggressive anticoagulation techniques to reduce VTE there are no data that show a decrease in incidence of death from thromboembolic events. Complications from aggressive anticoagulation are notably greater and include hematoma, drainage, increase infection rate, and blood loss (often requiring transfusion). In this light the orthopedic community has moved to a more cautious approach to anticoagulation using risk stratification for appropriate VTE prophylaxis.
Although the adoption of a 21st century blood management program appears straightforward, it requires a concerted effort by the health care team to be effective. A systems approach should allow the appropriate use of blood products and reduce the overall transfusion requirements for our TJA patient population. This should help to reduce the variable costs of joint arthroplasty within the framework of minimizing complications while maximizing our patient outcomes.
A note from the editors:
Look to the Cover Story in the March issue of Orthopedics Today for a more in-depth look at the options available for blood management in orthopedic surgery.
- Anthony M. DiGioia III, MD, is the editor of Emerging Technologies & Innovation. He can be reached at Renaissance Orthopaedics, PC, and Pittsburgh, Pennsylvania Innovation Center, Magee-Women’s Hospital of UPMC, Pittsburgh, Penn.
- Brian R. Hamlin, MD, is associate director of The Orthopaedic Program at Magee Women’s Hospital of UPMC. He can be reached at firstname.lastname@example.org
Disclosures: DiGioia is a shareholder in Blue Belt Technologies. Hamlin has no relevant financial disclosures.