Frequent use of blood-saving measures in elective orthopaedic surgery: a 2012 Dutch blood management survey

Abstract

BackgroundBlood loss in hip and knee arthroplasties may necessitate allogeneic blood transfusions. Different blood-saving measures (BSMs) were introduced to reduce these transfusions. Purpose of the present study was to assess the frequency of BSM use, stratified by type and hospital setting of orthopaedic departments in the Netherlands.MethodsAn internet-based questionnaire was sent to all heads of orthopaedic departments of Dutch hospitals and private clinics (n = 99). Questions were asked on how often BSMs were used, reported on a 5-point Likert scale (never, almost never, regularly, almost always, always). In addition there were questions about discontinuation of anticoagulants preoperatively, the number of annually performed arthroplasties (size) and hospital setting.ResultsThe survey was completed by 81 (82%) departments. BSMs used frequently (regularly, almost always, always) were erythropoietine (EPO), with 55 (68%) departments being frequent users; acute normovolemic hemodilution, used frequently in 26 (32%) departments; cell saver in 25 (31%) and postoperative drainage and re-infusion in 56 (69%) departments. When compared by size, frequent EPO use was more common in large departments (with 22 (88%) large departments being frequent users versus 13 (63%) small departments and 16 (55%) intermediate departments, p = 0.03). No differences by size or type were observed for other BSMs.ConclusionsCompared with previous survey’s there is a tremendous increase in use of BSMs. EPO and autologous blood salvage techniques are the most often used modalities. Costs might be saved if use of non-cost-effective BSMs is stopped.

Perceived barriers among physicians for stopping non–cost‐effective blood‐saving measures in total hip and total knee arthroplasties

“…However, participating physicians in the interviews stated using a restrictive transfusion protocol as mentioned in the national guideline, with triggers as low as 6.4 g/dL . These statements were in line with a previous survey among chairs of orthopedic departments in the Netherlands, where 96% of orthopedic departments reported using the national transfusion guideline or an extended version of this guideline . The risks for infections due to allogeneic transfusions like hepatitis B and C or human immunodeficiency virus were not mentioned as relevant risks of transfusion in the interviews, when explicitly asked about these risks.…”

“…A previous survey on the frequency of BSM use showed that more than 85% of Dutch hospitals frequently use either EPO, perioperative blood salvage, or a combination of these non–cost‐effective BSMs in THA and TKA …”

“…Despite the availability of this evidence, physicians keep using these BSMs in daily practice. A survey among orthopedic departments in Dutch hospitals showed that approximately 85% of Dutch hospitals use at least one of these BSM types frequently in THA and TKA patients …”

Towards a systematic approach for (de)implementation of patient blood management strategies

“…Blood salvage includes two modalities: first; intraoperative cell salvage, which is used during surgery in which a patients' blood is collected, washed, concentrated and then re‐infused, and second, a device that postoperatively collects, filters and re‐infuses autologous wound blood by means of a wound drainage and re‐infusion system (So‐Osman et al, ). Nowadays, the postoperative wound drainage system is used more commonly in primary arthroplasties opposed to intraoperative cell salvage, which is retained for more complex surgery such as revision arthroplasties (Voorn et al, ; Struijk‐Mulder et al, ; Sikorski et al, ). In a recent multicentre RCT, it was concluded that blood salvage was not effective to prevent exposure to allogeneic transfusion or to reduce the number of allogeneic red blood cell units transfused in primary elective THA and TKA and therefore could be considered low‐value care (So‐Osman et al, ,b).…”

“…The problem analysis of the LISBOA study consisted of two parts. Current use was assessed with a survey sent to all the heads of Dutch orthopaedic departments (Voorn et al, ). The survey demonstrated that 68% of the responders used ESAs on a regularly basis, intra‐operative cell salvage was used by 31% of responders, and postoperative drainage and re‐infusion was frequently used by 69% of the responders (response rate of the survey: 82%).…”