Orthopedics

Blood Management Experience: Relationship Between Autologous Blood Donation and Transfusion in Orthopedic Surgery

Thomas P Sculco, MD; Jessica Gallina, MD

Abstract

ABSTRACT

Preoperative autologous donation (PAD) is commonly used for patients undergoing elective total joint arthroplasty; however, PAD is associated with increased overall transfusion rates and may not be cost-effective for all patients. A retrospective analysis was conducted on a series of 1405 patients undergoing unilateral or bilateral total hip or total knee arthroplasty at The Hospital for Special Surgery to determine the effect of PAD on transfusion outcomes. Eighty-three percent of patients predonated blood (1 unit to 3 units). Transfusions occurred in 82% of PAD participants and in only 50% of nondonors. The allogeneic transfusion rates were 8% for PAD participants and 50% for nondonors. Thirty-four percent to 45% of donated autologous units were discarded. Hemoglobin concentrations measured prior to surgery were inversely related to frequency of allogeneic transfusion. These data underscore the importance of hemoglobin levels in blood management planning. This information can be useful for formulating rational, cost-effective blood management guidelines.

Abstract

ABSTRACT

Preoperative autologous donation (PAD) is commonly used for patients undergoing elective total joint arthroplasty; however, PAD is associated with increased overall transfusion rates and may not be cost-effective for all patients. A retrospective analysis was conducted on a series of 1405 patients undergoing unilateral or bilateral total hip or total knee arthroplasty at The Hospital for Special Surgery to determine the effect of PAD on transfusion outcomes. Eighty-three percent of patients predonated blood (1 unit to 3 units). Transfusions occurred in 82% of PAD participants and in only 50% of nondonors. The allogeneic transfusion rates were 8% for PAD participants and 50% for nondonors. Thirty-four percent to 45% of donated autologous units were discarded. Hemoglobin concentrations measured prior to surgery were inversely related to frequency of allogeneic transfusion. These data underscore the importance of hemoglobin levels in blood management planning. This information can be useful for formulating rational, cost-effective blood management guidelines.

INTRODUCTION

Perioperative blood management techniques for orthopedic surgery are critical to avoiding the risks and consequences associated with allogeneic blood transfusion. Despite stringent donor screening criteria and rigorous testing of every unit of blood, the risk of transmission of human immunodeficiency virus from allogeneic blood is estimated to be 1 in 493,000, while the risks of acquiring hepatitis C and B from allogeneic blood are 1 in 103,000 and 1 in 63,000, respectively.1 Other complications, such as allogeneic immunization and hemolytic reactions, can also significantly lengthen the duration of hospital stay,2,3 and allogeneic transfusion has been shown quantitatively to be an important contributor to postoperative infection.4 Because of the attendant blood loss during total joint arthroplasty, preoperative autologous donation (PAD) has become commonplace for some major elective procedures.5"7 The popularity of PAD can be attributed to its perceived safety and to its broad acceptance by the patient population.

PAD is just one of many alternative blood conservation strategies available to the surgeon. The refinement of transfusion practice standards, improvements in surgical technique, and the practice of perioperative blood salvage8,9 have contributed to a reduction in allogeneic blood requirements.10 Other alternatives to allogeneic transfusion include normovolemic hemodilution11 and perioperative therapy with recombinant human erythropoietin (Epoetin alfa; PROCRTT®, Ortho Biotech Inc., Raritan, NJ).12,15 Although PAD has emerged as a popular and generally effective approach to minimi zing the risks of allogeneic blood transfusion, it may not always be the best alternative. For instance, PAD has been shown to lower the patient's perioperative hemoglobin (Hb) and hematocrit (HCT) levels, thereby increasing the need for perioperative transfusion.16,17 In particular, patients who predonate 1 or more units of blood often do not exhibit a vigorous erythropoietic response to multiple phlebotomies; consequently, they are anemic at the time of surgery.18 Beris et al reported that the donation of 3 units of blood within 3 to 4 weeks reduced mean preoperative Hb levels by 2.4 g/dL.19 In addition, stored autologous units may contain suboptimal levels of red blood cells.18 Therefore, patients participating in PAD often have greater overall transfusion rates and may be at risk of exposure to allogeneic blood despite their predonation of autologous blood. Moreover, the cost-effectiveness of PAD remains controversial.20-22 Factors contributing to the cost of PAD include the special processing and storage requirements for autologous blood and the large proportion of discarded autologous units.23,24

Table

TABLE 1Patient demographic characteristics

TABLE 1

Patient demographic characteristics

Fig 1: Transfusions (autologous and/or allogeneic) in total hip arthroplasty (THA) patients and total knee arthroplasty (TKA) patients, stratified by participation or nonparticipation in a preoperative autologous donation (PAD) program.

Fig 1: Transfusions (autologous and/or allogeneic) in total hip arthroplasty (THA) patients and total knee arthroplasty (TKA) patients, stratified by participation or nonparticipation in a preoperative autologous donation (PAD) program.

Given these considerations, we conducted a retrospective analysis of a large series of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) at The Hospital for Special Surgery to determine the effect of PAD on perioperative transfusion rate. These findings provide additional insight into the role of PAD as a blood management tool in total joint arthroplasty.

MATERIALS AND METHODS

A retrospective case study review conducted at The Hospital for Special Surgery involved a series of 1405 patients who underwent elective orthopedic surgery for unilateral or bilateral THA or TKA between 1994 and 1996. For analysis, patients were stratified based on type of surgical procedure and participation in a PAD program. Patients were generally encouraged to donate autologous blood, but participation in the program was optional. Autologous blood orders for bilateral arthroplasties and for procedures in which complications were expected to arise were typically greater than for unilateral procedures.

All patients received daily oral iron supplementation, beginning several weeks before surgery. Regardless of surgical procedure, patients received epidural hypotensive anesthesia to reduce blood loss, shorten surgical time, and improve bony surfaces for implant fixation.25,26 The decision to transfuse (i.e., transfusion trigger) was based on the Hb level, cardiovascular history, and symptoms. Blood management options used at The Hospital for Special Surgery did not include hemodilution or blood salvage. Although the placement of drains was a routine procedure, no recovered blood was autotransfused.

Patient Hb measurements were made at preadmission testing, approximately 1 week before surgery. Predonation Hb levels for patients who autodonated are not available for direct comparison with Hb levels of nondonor patients.

RESULTS

Patients. Unilateral and bilateral THAs were performed on 616 and 26 patients, respectively, and unilateral and bilateral TKAs were performed on 543 and 220 patients, respectively (Table 1). Across all procedures, 1162 of 1405 (83%) patients participated in the PAD program. Mean preadmission Hb values were similar for all patient groups; however, Hb was measured in the autodonors after the donation of either 1 unit or 2 units of blood, thereby underestimating the predonation Hb level of the group.

Table

TABLE 2Proportion of all patients transfused, stratified by preoperative hemoglobin level

TABLE 2

Proportion of all patients transfused, stratified by preoperative hemoglobin level

Transfusion Frequency. The frequency of transfusion was compared between patients who participated in PAD and patients who did not (Fig 1). For those patients who underwent THA, 447 of 529 (84%) patients who participated in PAD were transfused, compared with only 59 of 113 (52%) patients who did not participate in PAD. Similarly, in the TICA cohort, 506 of 633 (80%) patients who participated in PAD were transfused, compared with only 62 of 130 (48%) patients who did not participate in PAD. Thus, the group of patients that donated blood preoperatively had approximately a 60% greater blood transfusion rate in comparison with nondonors.

When the overall patient population was stratified according to preadmission Hb level, an inverse relationship emerged between the frequency of blood transfusion (allogeneic and/or autologous) and Hb level (Table 2). In patients with preoperative Hb levels < 11 g/dL, approximately 93% to 96% of patients required blood transfusion, compared with 52% to 59% of patients with preoperative Hb levels ≥ 14 g/dL.

Fig 2: Percent of total hip arthroplasty patients (A) and total knee arthroplasty patients (B) in the autodonor group who were transfused with allogeneic blood, stratified by preoperative hemoglobin.

Fig 2: Percent of total hip arthroplasty patients (A) and total knee arthroplasty patients (B) in the autodonor group who were transfused with allogeneic blood, stratified by preoperative hemoglobin.

Exposure to Allogeneic Blood. The patients who autodonated had markedly lower allogeneic transfusion rates compared with patients who did not autodonate; however, participation in PAD did not necessarily eliminate exposure to allogeneic blood. A significant number of PAD participants, ranging from approximately 4% to 17%, still required allogeneic transfusion (Fig 2). The risk of exposure to allogeneic blood correlated inversely with preoperative Hb levels and appeared to increase at a greater rate when preadmission Hb values fell below 12 to 13 g/dL (Table 3).

Table

TABLE 3Allogeneic transfusion rates in nondonors, stratified by preoperative hemoglobin level

TABLE 3

Allogeneic transfusion rates in nondonors, stratified by preoperative hemoglobin level

Table

TABLE 4Autologous blood use

TABLE 4

Autologous blood use

Autologous Blood Use. Autologous blood use within the PAD group was assessed to determine the proportion of discarded stored units. Among patients who autodonated and had unilateral THA, 81 of 505 (16%) patients were not transfused, but none of the 24 patients who had bilateral THA avoided transfusion. Among PAD participants who had TKA, 22% of patients undergoing unilateral procedures and 15% of patients undergoing bilateral procedures were not transfused (Table 4). Based on the total units of blood predonated, 34% to 45% of stored units were discarded. The discard rate was slightly higher for TKA than for THA.

The mean number of units of autologous blood collected was relatively consistent across the two procedural groups (THA and TKA), averaging approximately 1.7 units to 2.0 units, and did not correlate with preoperative Hb values (Fig 3). Transfusion requirements, however, correlated inversely with preoperative Hb. For patients undergoing THA, transfusion requirements ranged from 0.8 unit when preoperative Hb was ≥ 14 g/dL to 1.6 units when preoperative Hb was < 11 g/dL. Likewise, for patients undergoing TKA, transfusion requirements ranged from 0.6 unit when preoperative Hb was ≥ 14 g/dL to 1.4 units when preoperative Hb was < 11 g/dL. Consequently, the average number of units of autologous blood discarded increased as Hb level increased. On average, patients with a preoperative Hb ≥ 13 g/dL predonated approximately 1 unit of blood more than was necessary for either hip or knee procedures because the amount of blood transfused (≤ 1 unit) was typically less than what they had donated (≡ 2 units).

DISCUSSION

The significant blood loss that can occur during orthopedic surgery makes perioperative blood management an issue of primary concern to the orthopedic surgeon. Allogeneic transfusion, historically, has been the principal means to meet the immediate need to increase a patient's HCT and may be the only option in an acutely injured patient. For elective surgery, however, there is adequate time for preoperative planning, and PAD has become a common practice for patients undergoing THA or TKA. The initial rationale for PAD was sound, but its use has raised some clinical and cost-effectiveness issues. Now, after more than a decade of experience with PAD, new information may help us to reevaluate the role of PAD in orthopedic surgery and to tailor blood management options to the specific needs of the individual patient.

At The Hospital for Special Surgery, medically stable patients scheduled for elective orthopedic procedures are given the option to participate in a PAD program. In the current series, 83% of patients elected to participate in the PAD program, but these patients were more likely to require a perioperative transfusion. Of the patients who participated in PAD, 82% overall were transfused, compared with only 50% of nondonors. Similar observations have been reported previously. 16,n One possible explanation for this significant difference is that surgeons may transfuse patients more readily if they have autologous units easily accessible.27

Another important explanation for the increased rate of transfusion among PAD participants may be that those patients had lower preoperative Hb levels. However, because predonation (i.e., true baseline) Hb levels are not available for this cohort, this conclusion cannot be drawn for this study. Several other studies have demonstrated that PAD can reduce Hb and HCT levels.1618 It has been reported that donating 3 units of autologous blood in a 3- to 4-week period diminishes Hb concentrations by approximately 2.4 g/dL.19 This observation is supported indirectly by the demonstration in the current series that transfusion rate inversely correlated with preoperative Hb (Table 3). Essentially, PAD can decrease perioperative Hb levels, contribute to preoperative anemia, and increase overall transfusion requirements.

In addition to the above considerations, the cost-effectiveness of PAD is affected by the substantial amount of autologous blood that is discarded.23,24 More careful consideration should be given to minimising this waste, and predicting transfusion needs more accurately is one approach. The current study suggests that blood needs vary based not only on the type of procedure, but also on the patient's preoperative Hb level. For patients with a preoperative Hb ≥ 13 g/dL, autologous blood collection appeared to exceed blood need by approximately 1 unit because patients generally donated approximately 2 units and on average tended to be transfused with less than 1 unit. Similar results were reported by Bernstein et al.23 On average, in a series of 182 TKA patients, 2.1 units were donated, but only 1.1 units were transfused. In contrast, however, in a series of 123 THA patients the average numbers of units of autologous blood donated and transfused were equivalent (2.4 units versus 2.3 units, respectively). Therefore, for some patients, blood-ordering criteria could be more conservative, particularly for TKA when the patient's preoperative Hb is ≥ 13 g/dL. In this way, the cost-effectiveness of PAD might be improved. THA patients, in general, and total joint arthroplasty patients with anemia, generally require more blood management intervention than other patients.

Fig 3: Units of autologous blood donated, transfused, and discarded (wasted) in total hip arthroplasty patients (A) and total knee arthroplasty patients (B) stratified by preoperative hemoglobin.

Fig 3: Units of autologous blood donated, transfused, and discarded (wasted) in total hip arthroplasty patients (A) and total knee arthroplasty patients (B) stratified by preoperative hemoglobin.

CONCLUSION

Most patients undergoing total joint arthroplasties were able to participate in PAD; however, a large proportion of the autodonated blood was not transfused and had to be discarded. Nevertheless, compared with nondonors, patients who autodonated had a higher frequency of transfusion, and for some patients, allogeneic blood was used in addition to autologous blood. The frequency of both autologous and allogeneic blood transfusion increased as preoperative Hb values decreased. Therefore, the apparent paradox of high blood waste and high transfusion rates among PAD participants suggests that blood management should be customized to meet the needs of the individual patient.

REFERENCES

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TABLE 1

Patient demographic characteristics

TABLE 2

Proportion of all patients transfused, stratified by preoperative hemoglobin level

TABLE 3

Allogeneic transfusion rates in nondonors, stratified by preoperative hemoglobin level

TABLE 4

Autologous blood use

10.3928/0147-7447-19990102-05

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