Changing Transfusion Practice in Total Hip Arthroplasty: Observational Study of the Reduction of Blood Use Over 6 Years

Abstract

Patients undergoing primary total hip arthroplasty (THA) have historically been over-transfused. In a district general hospital setting, the authors observed a significant downward trend in blood transfusion requirements in these patients over 6 years after a change in transfusion policy. The purpose of this study was to retrospectively analyze the change in transfusion practice and present the results of the restrictive transfusion policy. All patients undergoing primary THA between January 2003 and December 2008 were identified from hospital records. Pre- and postoperative hemoglobin levels, transfusion trigger hemoglobin, blood transfusion requirements, patient age and sex, 30-day mortality, and length of stay data were analyzed for all patients. A total of 1169 primary THAs were performed. Annual allogeneic blood transfusion requirements reduced progressively from 151 units in 2003 to 90 units in 2008 despite an increase in the number of patients undergoing THA. During this period, the proportion of patients transfused decreased from 35% to 17%. A reduction of mean transfusion trigger hemoglobin from 79 to 73 g/L was observed over the study period. No patient experienced any significant complications as a result of undertransfusion. The authors' institution has steadily restricted the use of blood transfusion in patients undergoing THA to those symptomatic of anemia. Increasing confidence among medical and nursing staff that reduced postoperative hemoglobin levels can be safely tolerated has resulted in a 55% reduction in blood transfusion in patients undergoing THA with no other change of practice.

Transfusions and blood loss in total hip and knee arthroplasty: a prospective observational study

“…Borghi et al reported allogeneic RBC transfusion requirements of only 10% for total hip and knee arthroplasty patients [ 24 ]. However, that study and other studies reporting low transfusion rates have been focused studies, investigating the use of a new transfusion protocol [ 25 , 26 ] or the use of autologous transfusion programs [ 27 ]. It is difficult to compare studies since, besides differences in study design and study populations, some investigators only included postoperative transfusions but not intraoperative ones in their analysis.…”

Assessing Changes in Mortality Trends Following Total Hip or Knee Arthroplasty Over Time: Comment on the Article by Lalmohamed et al

“…Moreover, THA and TKA are the leading indications for blood transfusion in surgical patients, and blood transfusion is an independent predictor of increased postoperative mortality, especially for patients with preoperative anemia and comorbidities (). Because initiatives to reduce the frequency of perioperative blood transfusion are being taken worldwide, decreasing utilization of blood transfusion in patients undergoing THA and TKA has recently been noted (). Thus, we cannot exclude the possibility that changes in transfusion practice in THA or TKA over the last 2 decades have confounded interpretation of Lalmohamed and colleagues' results.…”