Preoperative anaemia is present in 20-40% of patients scheduled for major elective orthopaedic procedures. A low haemoglobin (Hb) level is the main independent risk factor to receive an allogeneic blood transfusion (ABT). An orthodox approach to the patient blood management (PBM) paradigm recommended that patients scheduled for major orthopaedic procedures should have a full blood cell counts, iron status and some inflammatory markers tested, preferably 30 days before the scheduled surgical procedure, to allow the implementation of appropriate treatment, if available (mainly with iron). For patients presenting with moderate anaemia (Hb level between 10 and 13 g/dL) but without iron deficiency and/or with clinical or laboratory signs of inflammation, preoperative administration of recombinant human erythropoietin has been proven to increase haemoglobin levels and reduce the rate of allogeneic blood transfusion. Several consensus documents, such as the recent “Seville Document Update”, do not recommend the routine use of preoperative autologous blood donation (PABD) in patients scheduled for primary unilateral lower limb arthroplasty.
This retrospective study presents the results of a pragmatic approach to PBM in primary total hip arthroplasty (THA), which was successfully implemented at the Hospital for Special Surgery in New York (2350 THA procedures performed by only 13 surgeons between October 2009 and May 2013). A total of 2252 patients were preoperatively screened by the Blood Preservation Center. Overall, 2251 total hip arthroplasties (96%) were performed according to the protocol. Slightly anaemic patients (16%) (locally defined as Hb level lower than 12.5 g/dL but higher than 10.0 g/dL) were invited to donate only one PABD unit between one and two weeks before surgery (never less than 7 days). Only 280 (76%) of 367 anaemic patients donated. No patient with an Hb level less than 10.0 g/dL donated, and such patients usually have their procedures postponed until the anaemia is investigated and treated.
In the context of a restrictive approach for ABT, PABD significantly reduced the need for ABT in anaemic patients (13 vs. 37%; P < 0.001). The ABT transfusion rate for non-anaemic patients was 8%. Only 12 non-anaemic patients donated autologous blood and none of them required ABT. This retrospective study has a number of limitations. Some differences were between surgeons. Strict transfusion guidelines were not enforced for autologous blood transfusions. Although the authors state that only 6% of PABD units donated by anaemic patients were wasted, the real figure was around 50% of all unit donated.
Although the orthodox view holds that early preoperative anaemia assessment, classification and management is preferred, data from recent pragmatic approaches suggest that anaemia treatment should always be attempted in major orthopaedic procedures, as any time may be a good time for patients to benefit from it. Each centre should develop its own locally adapted PBM protocol. The results of this simple, unorthodox approach could still support the use of targeted PABD in selected patients undergoing primary THA. Selecting patients at highest risk for postoperative transfusion maximizes the efficacy of any ABT alternative, especially PABD, and significantly reduces the overall number of ABT as well as the number of autologous units wasted as compared to a routine predonation protocol for all patients.
– José Antonio García-Erce
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