Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation.

Perazzo et al. retrospectively reviewed perioperative data of 461 patients undergoing total joint arthroplasty (primary total knee or hip arthroplasties) who were managed with perioperative cell salvage (PCS) (143 total hip arthroplasties [THA] and 136 total knee arthroplasties [TKA]) or PCS + preoperative autologous blood donation (PABD) (1 unit per patient) (100 THA and 82 TKA), to assess the true effectiveness of these blood conservation strategies to avoid allogeneic blood transfusions and their associated risks.

The overall transfusion rate was higher in the PABD + PCS group than in the PCS group (13.7% vs. 6.1%, respectively; OR 2.45; 95% CI 1.28-4.69; P = 0.005), irrespective of the surgical procedure. The preoperative hemoglobin (Hb) level was found to be a useful indicator of transfusion probability. Interestingly, no patient in the PABD + PCS group received allogeneic blood transfusion, but 83% of autologous collected units were discarded. Thus, PABD increased the odds of receiving a red blood cell transfusion (overall rate), whereas PCS alone was found to limit adverse effects in cases of severe postoperative blood loss and rendered PABD virtually unnecessary (allogeneic transfusion rates: 6.1% vs. 0%, for PCS and PCS + PABD, respectively). In addition, the postoperative net decrease in Hb level was greater with PCS + PABD than with PCS alone.

Overall, these data add to the concept that PABD in primary THA or TKA may be regarded as useless if not harmful. In contrast, the combination of PABD (2-3 units per patient) + PCS could be useful in bilateral procedures or in revision arthroplasties. These results agree with the recommendations of the recent Spanish Consensus Document on Alternatives to Allogeneic Blood Transfusion (“2013 Seville Document Update”). In this evidence-based documment, the routine use of PABD in patients scheduled for orthopedic surgery with an expected transfusion of two or less units (mainly primary unilateral lower limb arthroplasty, THR or TKR) is not recommended (level of recommendation 1B).

However, PABD can be considered for: 1) procedures with a high transfusion risk and generally requiring more that 2 units of allogeneic blood (e.g., revision or bilateral total arthroplasty, complex spinal surgery), preferably with adjuvant treatment with iron and rHuEPO; 2) patients for whom compatible allogeneic blood is difficult to find; and 3) patients who refuse to receive allogeneic blood but accept PABD (Recommendation 1C). Furthermore, for the few indications that are recommended, the PABD program should only be implemented in those centers in which interdepartmental coordination is adequate to guarantee the date of surgery and the time interval prior to the scheduled procedure (to allow sufficient red blood cell regeneration).

– José A. García-Erce