Acute blood management with THA may reduce anemia, side effects

Transfusing allogeneic blood is an option that is readily available, low cost and safe compared to other transfusion types.

Issue: January 2005

Patients with low hemoglobin levels at the time that total hip arthroplasty is indicated may respond well to some of the newer surgical blood management techniques, such as erythropoietin and postoperative autologous reinfusion, according to John J. Callaghan, MD, professor of orthopedic surgery and bioengineering at the University of Iowa.

For some of those patients, making predonation deposits or receiving an allogeneic transfusion intraoperatively may not be an acceptable option, he said.

Callaghan, a member of the joint reconstruction section of the Orthopedics Today Editorial Board, discussed ways of managing blood loss in the pre-, post- and perioperative setting and why doing this is important in a presentation at the 21st Annual Current Concepts in Joint Replacement Winter 2004. “What we have to realize is there is a lot more blood loss than we think following total joint arthroplasty (TJA).”

Reduce perioperative anemia

John J. Callaghan, MD [photo] John J. Callaghan, MD, observes patients with >8 g hemoglobin after THR and tries to treat their hypovolemic symptoms with more aggressive fluid resuscitation.

The goal of using blood management techniques in the TJA setting, particularly for total hip arthroplasty (THA), is “to reduce the need for transfusion, to avoid allogeneic blood, to cause the fewest potential side effects, and to offer the greatest potential for benefit by reducing the anemia of that acute blood loss and its associated sequelae. In addition, this should be done in a cost-effective manner,” he said.

Among the statistics concerning blood loss during THA that Callaghan cited during his presentation and its abstract were the following:

Approximately 4 g of hemoglobin is lost during THA and total knee replacement (TKR) surgery.
Bilateral TKR may lead to blood losses totaling 5 g to 6 g.
Most patients can tolerate losing up to 25% of their blood volume.
With 30% blood loss patients become hypovolemic; a 50% blood loss may be lethal.

Some common effects from blood loss during surgery include acute anemia, fatigue, confusion, reduced vigor, delayed wound healing and depressed cardiac function. Callaghan emphasized reduced vigor as a side effect to be avoided because “as we try to send people home earlier and earlier, it might become an issue … Whatever [blood management] method you use, it may be beneficial to keep their hemoglobin up because of that.”

Several risk factors

For healthy patients undergoing primary THA almost any kind of blood management program can be used. But for patients who have risk factors related to transfusion, special interventions may be required. Those factors can involve low preoperative hemoglobin, low blood volume, weight, age, amount of anticipated blood loss and patient comorbidities. Aspirin use is probably less problematic than previously thought.

“I think the one thing we’ve really learned over the years is that all patients are different,” Callaghan said.

A newer approach to consider is using erythropoietin, which is indicated for those people with hemoglobin counts of 10 to 13 who are not suited for autodonated blood. Patients receive four doses starting 21 days before surgery. “Every study related to this shows that for that 10 to 13 hemoglobin group, it is effective,” said Callaghan.

But using this method is also costly.

The protocol Callaghan currently uses: Patients with >8 g hemoglobin after surgery are observed and receive allogeneic blood as needed. Erythropoietin is used in THA patients with expected hemoglobin levels <8 g postoperatively.

With all of these methods, not wasting donated blood is important.

For more information:
Callaghan JJ. Blood management options: What’s in, what’s out? #31. Presented at the 21st Annual Current Concepts in Joint Replacement Winter 2004. Dec. 8-11, 2004. Orlando, Fla.