Drivers of Transfusion Decision Making and Quality of the Evidence in Orthopedic Surgery: A Systematic Review of the Literature

Barr, Paul; Donnelly, Michael; Cardwell, Christopher; Alam, Shama S.; Morris, K.; Parker, Michael; Bailie, K.

doi:10.1016/j.tmrv.2011.04.003

Cited by 49 publications

(38 citation statements)

References 61 publications

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“…A transfusion frequency of 30% to 40% has been reported in a publication regarding new anticoagulants [16], and a review on transfusion decision-making reported between 16% and 50% of patients who had THAs received transfusions [1]. We found similar percentages: 30% with preoperative and 12.5% with postoperative thromboprophylaxis.…”

Section: Discussionsupporting

confidence: 74%

“…Our study was not powered to show differences in transfusions and we observed no differences in total units transfused, frequency of transfusions, or number of patients who had transfusions. Parameters known to affect transfusion requirements, such as preoperative and postoperative hemoglobin level, American Society of Anesthesiologists physical status classification, weight, and age [1], were similar in both groups and should not influence the results. However, fewer patients received blood transfusions and the number of RBC units transfused was less in the postoperative group.…”

Section: Discussionmentioning

confidence: 82%

“…We recorded hemoglobin, hematocrit, and volume of fluids transfused at fixed times during and after surgery and found these recordings consistent across the two groups and followed the same pattern. Third, our transfusion guidelines leave a gray zone between upper and lower transfusion thresholds where transfusion decisions are based on numerous factors, including preoperative and postoperative hemoglobin levels, age, BMI, additional comorbidities, physicians preferences, and others [1,2,25]. However, as there were no differences in any parameters between the two groups, we consider the decision to transfuse to be equal in the two groups.…”

Section: Discussionmentioning

confidence: 99%

“…We used a standard protocol with transfusion thresholds where a hemoglobin level less than 8 g/dL triggered transfusion and patients with a level greater than 10 g/ dL did not receive a transfusion. Hemoglobin level on its own may be a poor indicator of tissue hypoxia, and the decision to transfuse patients with hemoglobin between 8 and 10 g/dL will, to some extent, be influenced by other parameters such as concomitant disease, weight, age, and others [1]. RBCs were given in 300-mL units, and autologous blood was not used.…”

Section: Methodsmentioning

confidence: 99%

“…We therefore asked if (1) there is a clinically important difference in total blood loss in THA between preoperative or postoperative start of thromboprophylaxis, and (2) there is a difference between the two regimens in transfusion requirements, incidence of bleeding events, and other complications detected up to 6 months after surgery.…”

Section: Introductionmentioning

confidence: 99%

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Blood Loss in Cemented THA is not Reduced with Postoperative Versus Preoperative Start of Thromboprophylaxis

Borgen

Dahl

Reikerås

2012

Clinical Orthopaedics &Amp; Related Research

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Background Thrombin formation commences perioperatively in orthopaedic surgery and therefore some surgeons prefer preoperative initiation of pharmacologic thromboprophylaxis. However, because of the potential for increased surgical bleeding, the postoperative initiation of thromboprophylaxis has been advocated to reduce blood loss, need for transfusion, and bleeding complications. Trials on timing of thromboprophylaxis have been designed primarily to detect thrombotic events, and it has been difficult to interpret the magnitude of blood loss and bleeding events owing to lack of information for bleeding volume and underpowered bleeding end points. Questions/purposes We therefore asked whether there are differences in blood loss, transfusion requirements, and other postoperative clinical complications with preoperative versus postoperative start of thromboprophylaxis with dalteparin. Methods In a double-blind, randomized controlled trial, 80 patients undergoing primary cemented THA were allocated to dalteparin injections starting 12 hours before or 6 hours after surgery. Blood loss was measured by weighing sponges and drapes, volume in suction drains during surgery, and wound drains until removal 24 hours postoperatively. Hemoglobin and hematocrit were recorded at predefined times during and after surgery. Results We found no differences in blood loss (1081 mL ± 424 mL versus 1023 mL ± 238 mL), bleeding-related events (10% versus 17%), or number of patients who had transfusions (12 versus five) with preoperative and postoperative thromboprophylaxis, respectively. Other complications were few in both groups. Conclusions Our data suggest blood loss is similar with preoperative and postoperative initiation of dalteparin thromboprophylaxis, but indicate a trend toward fewer transfusion requirements which might favor postoperative start of thromboprophylaxis.

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Section: Discussionsupporting

confidence: 74%

Section: Discussionmentioning

confidence: 82%