The orthopaedic surgery specialty in Europe and elsewhere has
traditionally been slow to adopt
blood management practices for those procedures resulting in
the greatest amount of
blood loss hip, knee, spine and trauma surgeries.
Research has shown the extent of blood loss in such cases is mostly related to
the procedure, surgeon and implant used, highlighting the need for safer, more
effective and standardized blood management protocols.
National guidelines, political factors, and strong medical tradition,
rather than evidence-based medicine, have long affected the methods that
European orthopaedic surgeons use in managing their patients potential
blood loss. Therefore, some have proposed developing an international manual to
help standardize blood management practices.
Among the current challenges in this area are guidelines that differ
from one country to another or convey contradictory information, such as what
is an acceptable preoperative hemoglobin level. Concerning
anemia management, many European centers are aware of
effective blood management techniques, but experts told Orthopaedics
Today Europe strict surgical schedules can prevent delay of surgery to
What is more, no formal blood management training programs exist,
resulting in a trend for new surgeons to transfuse blood more liberally than
more experienced surgeons.
In total hip arthroplasty cases, Ove Furnes, MD,
PhD, and colleagues at Haukeland University Hospital in Bergen, Norway, do not
normally opt for blood reinfusion techniques, but may use cell savers for spine
Image: Haukeland University Hospital
Normally, for knee replacements, we use a tourniquet and we give
10 mg of
tranexamic acid 10 minutes before the tourniquet and the same
amount 10 minutes before the tourniquet is released, Ove Furnes, MD, PhD,
head of the Department of Orthopaedic Surgery at Haukeland University Hospital
in Bergen, Norway, told Orthopaedics Today Europe. Good
hemostasis and good operating technique should of course be part of
standard practice, he said.
Furnes said his teams blood management program is typical of those
used at many Norwegian hospitals. For
total hip arthroplasty (THA) and
total knee arthroplasty (TKA), surgeons preoperatively screen
hemoglobin levels to identify possible anemia cases and predict which patients
may need postoperative transfusions. They typically do not use hemostatic
agents or platelet gels except in special cases, relying instead on tranexamic
acid to clear the surgery site peri-operatively and postoperatively, according
For large back surgeries, a cell saver is sometimes used, he said.
There are several issues that need to be studied, such as if it is
necessary to use drains postoperatively and how different regimes of
antithrombotic prophylaxis and their timing affects blood management, he
said. It is also a question if you should use a tourniquet and if you use
it, when to release it.
Practice based in tradition
Autologous blood donation and reinfusion is almost non-existent in
Norway due to a good allogenic blood bank system. The risks associated with
allogenic transfusion, including disease transmission and adverse reactions,
are essentially eliminated in the country due to strict blood supply screening
and an otherwise homogenous population, hence there is a lack of interest in
self-donating blood, Furnes said.
But that is not the case with every countrys blood bank practices.
Athanasios Zacharopoulos, MD, in the Department of Orthopaedics at
Greeces General Hospital of Amfissa, said autologous blood donation has
been a part of his TKA routine for the past 10 years.
I mainly use a postoperative unwashed autologous blood reinfusion
system, he told Orthopaedics Today Europe. This method
resulted in a reduction of homologous blood reinfusion by 91% and of the cost
by 76%. In my series, following the indications of the system strictly, I have
not observed any adverse reactions after the reinfusion.
I think there
is an increased interest among orthopaedic surgeons about how to eliminate the
need for homologous blood requirements.
Athanasios Zacharopoulos, MD
I think there is an increased interest among orthopaedic surgeons
about how to eliminate the need for homologous blood requirements. Further
knowledge of the alternative to allogenic transfusion methods and their
efficacy can convince them to try it, Zacharopoulos said.
Gilles Folléa, MD, PhD, executive director of the European Blood
Alliance, an Amsterdam-based association of blood establishments in 23
countries, said such blood management discrepancies are common from country to
At the moment, we could say there is no real European consensus on
these issues, he noted. The organizations of blood transfusion
services or blood transfusion activities are very different from country to
country in Europe.
Depending on the area of Europe, blood management and regulation can be
either highly competitive or almost completely based in state organizations.
Some countries, like Germany, have non-profit organizations competing with
commercial companies whereas in the United Kingdom and France there is no
competition due to a state monopoly on blood organizations, according to
You can envision one of the problems faced by many countries in
Europe is that with the connections for the information between hospitals on
one side, with the need for patients and the blood establishment on the other,
this relationship is not well established, Folléa said.
Sometimes it is very difficult to have a good connection between both and
it is a [cause] of some issues. You could have a real difference in policies
and outcomes from this.
Whether surgeons prefer
allogenic transfusion, busy schedules sometimes allow for
little time to screen for anemia even though raising hemoglobin levels to
accepted levels might reduce or eliminate the need for a transfusion
Øivind Jans, MD, a research fellow in the Surgical
Pathophysiology section at Rigshospitalet in Copenhagen, said not treating
anemia preoperatively is a major reason why many transfusions are done in his
It is quite a new field in Denmark. But, the problem in the
treatment of preoperative anemia is most controversial because often there is
not enough time to do that, he said.
Raising a patients hemoglobin prior to the scheduled surgery can
be challenging and it is also a lot of work to reschedule the surgery, Jans
A discrepancy also exists between the day and night shifts in hospitals.
In some centers, junior doctors will transfuse more liberally because a nurse
suggested it without the attending surgeons knowledge. This communication
gap leads to surgeons not being aware of all transfusions performed because
they did not initially authorize them, according to Jans.
While many bloodless surgery agents are available to control
bleeding and keep hemoglobin levels in check, their cost effectiveness is
debated. A prospective, randomized trial across six European countries by Weber
and colleagues in the European Journal of Anaesthesiology showed
epoetin alfa increased hemoglobin levels peri-operatively and helped prevent
transfusion-related complications like infection. While there is a benefit to
using the agent, Jans and others question its safety in normal surgery,
preferring other bloodless agents such as low-cost tranexamic acid.
Many [centers] now use tranexamic acid to avoid excessive bleeding
or to reduce bleeding and some centers have started to get rid of drains,
Good scoliosis surgery technique
Geraldine Edge, PhD, FRCA, senior anesthetist at the Royal National
Orthopaedic Hospital in London, said a conscientious surgeon manages blood loss
by using a minimally invasive technique, which goes a long way to prevent blood
loss, particularly in scoliosis surgery, an area in which her hospital
Surgeons who do spinal surgery have a very high awareness of blood
loss, especially the pediatric surgeons who are doing the big pelvic
osteotomies and so on. They are very tuned in to blood loss and what a problem
it can be, Edge told Orthopaedics Today Europe.
anesthetist, I think the single most important way of controlling blood loss is
to have a surgeon who is aware.
Edge, PhD, FRCA
Although these spinal and pediatric surgeons have mastered effective
approaches to blood loss, she said there is room for improvement in primary THA
and TKA cases at her hospital; despite the predictability of blood loss during
these standard procedures, no attempt is made to optimize
patients hemoglobin by use of hematinics prior to surgery, she said.
As an anesthetist, I think the single most important way of
controlling blood loss is to have a surgeon who is aware. In terms of
controlling blood loss, your surgery site is very important, Edge said,
stressing that in spine procedures care with patient positioning makes a
lot of difference to how much blood is being lost.
Religious and cultural tolerance
One considerable challenge in blood management involves patients whose
religion or culture prohibits blood transfusion. In general, European
orthopaedists will use cell salvage in such cases when significant blood loss
is expected. However, the idea of a system that has no discontinuity between a
patients body and the blood is sometimes still not enough to convince
patients to proceed with a procedure that may be life-threatening.
Some patients just refuse [a procedure] empirically if it is going
to be associated with blood loss, Edge explained, saying that sometimes
leaves trying to convince them to go through with it as the only option.
When consulting with the patient proves unconvincing, she said her
hospital has a Jehovahs Witness liaison group that reviews with the
patient the system used and it has proven effective in persuading many patients
to proceed with the needed treatment.
Folléa told Orthopaedics Today Europe, To me,
the biggest problem is the differences [in blood loss] between surgical
operations, showing you could educate clinicians and surgeons to do better in
order to reduce the need for blood.
To this end, the health authority section of the Council of Europe, a
47-country effort focused on the wellness of European citizens, has enlisted a
community of experts on transfusion to identify and analyze the best blood
supply management practices in Europe.
We would like to identify good practices in blood supply
management processes in order to organize a meeting to share the results of the
survey and really try to write a manual of good practices of blood supply
management, said Folléa, who is a chairperson for a blood
management research group.
More recently, groups, like the Network for Advancement of Transfusion
Alternatives, founded in Austria, hold open symposiums on the subject to
educate doctors in proper blood management in everyday surgery.
There is a real movement to assess and benchmark what the
practices are today, what could be the best practices, and how to disseminate
good practices in blood management, at least at the European level, but also
[globally], Folléa said. by Jeff Craven
- Weber EWG, Slappendel R, Hémon Y, et al. Effects of epoetin
alfa on blood transfusions and postoperative recovery in orthopedic surgery:
the European epoetin alfa surgery trial (EEST). Eur J Anaesthesiol.
- Geraldine Edge, PhD, FRCA, can be reached at the Department of
Anesthesia, Royal National Orthopaedic Hospital, 45 Bolsover St., Greater
London, United Kingdom; +44 208 909 5560; email:
- Gilles Folléa, MD, PhD, can be reached at the European Blood
Alliance, 17, Rue de Tabellion, Brussels, Belgium 1050; +31 6 228 09 178;
- Ove Furnes, MD, PhD, can be reached at Jonas Liesvei 65, 5021
Bergen, Norway; +47 55 97 56 80; email:
- Øivind Jans, MD, can be reached at Copenhagen University
Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark; +45 21 68 80 12; email:
- Athanasios Zacharopoulos, MD, can be reached at General Hospital of
Amfissa, Oikismos Drosochoriou, 33100 Amfissa, Greece; +30 22 65 03 51 10;
- Disclosures: Edge, Folléa, Furnes, Jans and
Zacharopoulos have no relevant financial disclosures.
Is reintroducing a patients blood part of your blood management
Better TKA techniques available
Currently, we do not use intraoperative or postoperative blood salvage
or autotransfusion, as there are other blood-saving techniques that have
reduced our transfusion rate.
One of the reasons against using these blood savers is that the drain
volume increases due to pressure exerted by aspiration. Moreover, its use does
not show a good cost/benefit relationship and its use may have adverse
reactions when receiving the blood as it has inflammatory factors,
hypercoagulability and an increase in interleukin-6. There is a reported case
of tracheal edema post-reinfusion of the recovered blood.
Preoperative autotransfusion, in my experience, is a technique that I no
longer use for several reasons. Firstly, there is an imbalance between the
removed bags and the transfusional ones, ending in an expensive and ineffective
measure. Secondly, the emergence of intravenous iron and erythropoietin (EPO)
has decreased the need for autotransfusion to patients for whom it is difficult
finding compatible blood.
Correction of anemia preoperatively by stimulation with EPO or iron
administration is important as preoperative hemoglobin concentration is one of
the utmost important predictive factors for autologous blood transfusion.
Routine use of tranexamic acid preoperatively and postoperatively has
been the key element in our decision making. Studies have shown its
administration in TKA significantly reduces blood by up to 50% and diminishes
transfusion requirements without increasing the risk of thromboembolic events.
Both in THA and spinal surgery, administering tranexamic acid prophylactically
reduces intraoperative blood loss without increasing the incidence of
In conclusion, I believe there are other techniques in addition to
autotransfusion and blood recoveries that enable us to reduce the transfusion
rate and maintain a correct blood volume.
Oscar Ares, MD, PhD, is an
orthopaedic surgeon specializing in knee surgery at Hospital Clinic Barcelona
and Hospital Quiron Barcelona in Barcelona.
Disclosure: Ares has no
relevant financial disclosures.
Autotransfusion inefficient in THA
Retransfusion of a patients blood is not a part of our blood
Our practice of blood management is the use of tranexamic acid which is
safe, efficient and cheaper than other modalities. Tranexamic acid reduces the
blood loss and transfusion requirement by 50% without increasing the risk of
deep vein thrombosis. Autotransfusion has the disadvantage of lowering the
patients hemoglobin as a result of phelobotomy-induced anemia, thereby
resulting in an increase in the overall rate of transfusion postoperatively. In
addition to adding to the cost, a high rate of wastage has also been reported
Blood salvage and reinfusion is only useful in cases with at least 2
units to 3 units of blood loss and may even cause coagulopathy if given in
large volume, as it lacks platelets and clotting factors. The reinfusion of
lysed red blood cells may also cause hemoglobinuria resulting in renal
Blood salvage also requires the use of expensive equipment, such as cell
Tranexamic acid is an economical and safe option for blood management.
Vijay Kumar, MS, is an orthopaedic
surgeon at the All India Institute of Medical Sciences in New Delhi, where he
focuses on joint replacement.
Disclosure: Kumar has no relevant