Autotransfusion in Major Orthopedic Surgery: Postoperative Evaluation

The aim of this prospective study was to assess the postoperative progress of autotransfused patients (predonated blood + intra and postoperative blood salvage) in major orthopedic surgery.

Patients

1,785 consecutively treated patients (1,198 females, 587 males), mean aged 62± 11 years, basal Hb 13.4± 1,4 g/dl.

Surgery

Total hip arthroplasty (THA, 1,229 pts), THA after the removal of internal fixation devices (RFD+THA THA 18), total knee arthroplasty (TKA 263 pts), hip revision (HR) (cup+stem THR 197, cupR 53, stemR 16 pts) and knee revision (KR 9 pts).

Results

Homologous tranfusions were carried out in 130 patients (7.3%). The need to use homologous transfusions was significantly associated to the female sex (8.5% vs 4.7%, p=0.0049), older age (67.8 vs 62.1 years; p=0.0001), lower baseline Hb (12.3 vs 13.5g/dl p=0.0001), use of Calcium Heparin (CaHe) for antithromboembolic prophylaxis (CaHe 18% vs low molecular weight heparin 7.8% vs Indobufen 5% p=0.0001), lower number of predeposits (zero 62.5% vs one 16.2% vs two 5.2% vs three 6.4% vs four 5.5%, p=0.0001), type of surgery (THR 16.2% vs cupR 11.3% vs RPS+THA 11.1% vs stemR 6.2% vs THA 6.1% vs TKA 5.7% vs KR 0%, p=0.0001), presence of coexisting diseases like coronary heart disease (15.7% vs 6.2%, p=0.0001), and nephropathy (18.7 vs 7.1%, p=0.031), higher ASA (ASA4 18.7% vs ASA3 10.1% vs ASA2 6.6% vs ASA1 0%, p=0.0001). Postoperative hospitalization was significantly shorter in patients only autotransfused (12.3 vs 16.5 days, p=0.0001). The result confirms the central role of the anesthesiologist in the application of blood saving techniques.

Reducing perioperative blood loss in patients undergoing total hip arthroplasty

In this prospective, randomised, double-blind study, we investigated the effect of epidural anaesthesia and an antifibrinolytic agent, Aprotinin (500,000 KIU in bolus before surgery and 500,000 KIU h-1 in drip form during surgery), on intra and postoperative blood loss and transfusion requirements in total hip arthroplasty. Sixty patients were allocated randomly to four groups (A: epidural + general anesthesia + Aprotinin, B: epidural + general anesthesia + placebo (equal volume), C: general anaesthesia + Aprotinin, D: general anaesthesia + placebo). Postoperative analgesia: epidural analgesia in groups A and B, systemic analgesia with opiates in groups C and D.

Blood loss during surgery was monitored and salvaged with the Compact-A Dideco, and postoperative blood loss with the BT 797 Recovery Dideco for the first 24 hours. Perioperative blood loss, frequency and quantity of transfusions were significantly higher in group D (p < 0.0001). Total blood loss was reduced by 31.3% by epidural anaesthesia, 20.4% by Aprotinin and 51.4% using a combination of the two techiniques.

Autotransfusion with Predeposit-Haemodilution and Perioperative Blood Salvage: 20 Years of Experience

Background

Through a prospective study, we evaluated the efficacy of an integrated autotransfusion regimen comprised of predeposit-hemodiluition and intra and post-operative blood salvage in major orthopaedic surgery.

Methods

We examined the records of 2303 consecutive patients (1524 females and 779 males, mean age 62.7, standard deviation 11 years (range 16–90 yrs), pre-operative haemoglobin (Hb) concentration 13.5 (SD 1.4) (range 6.7–19.3) g/dl undergong total hip arthroplasty (THA 1582 patients), THA after the removal of internal fixation devices (RFD+THA, 25 patients), total knee arthroplasty (TKA, 347 patients), revision surgery of the hip (HR, cup+stem revision, 248 patients; cup revision 64 patients; stem revision 23 patients) and total knee revision (TKR 14 patients). We estimated that the number of predonations (MSBOS - maximum surgery blood order schedule) was 2 units for THA, TKA and TKR, and 3 units for partial or total hip revision and for total hip arthroplasty with fixation removal.

Results

It was possible to obtain the MSBOS in 2070 patients (89.8%). Homologous red blood cell (HRBC) transfusion were carried out in 184 patients (8%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower pre-operative Hb concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, a higher ASA rating and co-existing diseases such as coronary artery disease.

Conclusions

Cooperation among anaesthesis, transfusionists and surgeons in the application of an integrated autotransfusion regimen enabled us to treat 92% of our patients with only autotransfusion.

Intensive Predeposit-Hemodilution Autologous Blood Donation and IOBS Increase in Erythropoietic Levels in Patients Undergoing Hip Arthroplasty

Erythropoietin (EPO) plasma levels were monitored during the perioperative period in 61 consecutive patients (22 males - 39 females), aged 62.5 ± 9.5 years, scheduled for hip arthroplasty. All patients underwent intraoperative blood salvage (IOBS) and were subdivided into three different groups according to their hemoglobin levels (Hb) 24 hours postoperatively (group A: Hb < 8 g/dl; group B: Hb between 8-9 g/dl; group C: HB ≥ 9 g/dl). Seventy-two hours after surgery EPO levels were significantly different in group A (135 ± 68) compared to group C (54.3 ± 32), with a positive correlation (p < 0.01) between Hb and EPO levels. On the basis of these results we suggest that a programmed autologous red blood cell collection aimed at obtaining the lowest hemoglobin values during the first 24 hours after surgery, may be of clinical utility in preventing homologous blood needs.

Predictors of blood transfusions in spinal instrumentation and fusion surgery

STUDY DESIGN

A retrospective review of 244 adult spine instrumentation and fusion surgery cases (1994-1995) from one institution.

OBJECTIVES

To ascertain the predictors of blood transfusions for adult patients undergoing different types of multilevel spine surgery.

SUMMARY OF BACKGROUND DATA

Blood loss and transfusion requirements during and after multilevel spine surgeries have always been perceived as great. Identifying the predictors of blood transfusion with this type of surgery may aid in reducing the amount of blood loss and the transfusion requirements.

METHODS

The charts of 244 adult patients who underwent multilevel spine surgery from January 1994 to July 1995 were retrospectively reviewed.

RESULTS

A large percentage of patients required blood transfusion. The significant determinants for increased amounts of allogeneic red blood cell units transfused on the day of surgery using linear multiple regression modeling were low preoperative hemoglobin concentration, tumor surgery, increased number of posterior levels surgically fused, history of pulmonary disease, decreased amount of autologous blood available, and no use of the Jackson table (R2 = 0. 63). The significant determinants for an increased amount of autologous red blood cell units transfused on the day of surgery using linear multiple regression modeling were increased autologous red blood cells available, low preoperative hemoglobin concentration, and increased number of posterior levels surgically fused (R2 = 0. 60).

CONCLUSION

The need for transfusion is associated with multiple factors, suggesting that a multifaceted, integrated approach may be necessary to reduce this risk.

Reducing Perioperative Blood Loss in Patients Undergoing Total Hip Arthroplasty

In this prospective, randomised, double-blind study, we investigated the effect of epidural anaesthesia and an antifibrinolytic agent, Aprotinin (500,000 KIU in bolus before surgery and 500,000 KIU h-1 in drip form during surgery), on intra and postoperative blood loss and transfusion requirements in total hip arthroplasty. Sixty patients were allocated randomly to four groups (A: epidural + general anesthesia + Aprotinin, B: epidural + general anesthesia + placebo (equal volume), C: general anaesthesia + Aprotinin, D: general anaesthesia + placebo). Postoperative analgesia: epidural analgesia in groups A and B, systemic analgesia with opiates in groups C and D.

Blood loss during surgery was monitored and salvaged with the Compact-A Dideco, and postoperative blood loss with the BT 797 Recovery Dideco for the first 24 hours. Perioperative blood loss, frequency and quantity of transfusions were significantly higher in group D (p < 0.0001). Total blood loss was reduced by 31.3% by epidural anaesthesia, 20.4% by Aprotinin and 51.4% using a combination of the two techiniques.