An individualized pre‐operative blood saving protocol can increase pre‐operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty

Abstract

We have prospectively evaluated the efficacy of an individualized pre-operative blood saving protocol in elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). The primary aim was to obtain a pre-operative haemoglobin (Hb) level of > or =14 g dL(-1). A reduction in requirements for allogeneic transfusion was considered the second aim. Several strategies are available for increasing pre-operative Hb levels and reducing red blood cell (RBC) transfusions following THA or TKA, but the success of these programmes depends on selecting the most appropriate treatment for each patient. Three hundred and five patients with an indication of elective THA or TKA were individually assigned to the following strategies according to Hb and ferritin levels and medical conditions: (a) no pre-operative intervention, (b) oral iron therapy, (c) intravenous (i.v.) iron therapy, (d) recombinant human erythropoietin alpha with i.v. iron and (e) pre-operative autologous donation (PAD) plus oral iron. Eighty-two percent of the patients reached a pre-operative Hb level of > or =14 g dL(-1) compared with 62% of patients with Hb levels of > or =14 g dL(-1) at the baseline visit. Treatment with PAD showed a significant reduction in the pre-operative Hb levels. The rate of RBC transfusion was 18.8% compared with 31.5% of matched historic group (P < 0.001). In conclusion, all patients scheduled to undergo THA or TKA should be candidates for an individualized pre-operative blood salvage programme.

The Use of Preoperative Epoetin-α in Revision Hip Arthroplasty

“…Gonzalez-Porras et al [13] studied 305 patients who either underwent elective THA or TKA. The patients were individually assigned to one of five strategies: (1) no pre-operative intervention; (2) oral iron therapy; (3) intravenous iron therapy; (4) recombinant human epoetin-α with intravenous iron; and, (5) pre-operative autologous donation plus oral iron.…”

“…They noted that preoperative autologous donation caused a reduction in hemoglobin levels. Furthermore, a multivariate subgroup analysis designed to evaluate postoperative transfusion risk factors determined that decreased weight and/or preoperative hemoglobin levels as well as the lack of a blood protocol strategy independently increased transfusion needs [13]. …”

Optimal Timing for Hemoglobin Concentration Determination after Total Knee Arthroplasty: Day 1 versus Day 2

“…Current evidence suggests, such restrictive practice is as effective and in some cases superior in critically ill patients than using more traditional liberal transfusion strategies9,10). Preoperative Hb concentration is also a significant predictor for postoperative transfusion in knee arthroplasty11). It is therefore critical to determine preoperative Hb concentration as part of a routine work-up and treat reversible causes of anaemia prior to surgery.…”

Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

“…Patient blood management (PBM) is a programme or collection of approaches tailored to the individual patient aimed at minimizing the need for red cell transfusion and thus improving postoperative outcomes. 80,[93][94][95][96][97][98] It centres on three 'pillars' (first, optimization of haemopoesis; second, minimizing blood loss and bleeding; and third, optimizing tolerance of anaemia) all of which have a preoperative, intraoperative and postoperative component. This approach is established in Australia and several centres in the USA but has been inconsistently adopted in Europe.…”