Orthopaedists require more education in effective and safe blood management

The orthopaedic surgery specialty in Europe and elsewhere has traditionally been slow to adopt blood management practices for those procedures resulting in the greatest amount of blood loss — hip, knee, spine and trauma surgeries. Research has shown the extent of blood loss in such cases is mostly related to the procedure, surgeon and implant used, highlighting the need for safer, more effective and standardized blood management protocols.

National guidelines, political factors, and strong medical tradition, rather than evidence-based medicine, have long affected the methods that European orthopaedic surgeons use in managing their patients’ potential blood loss. Therefore, some have proposed developing an international manual to help standardize blood management practices.

Among the current challenges in this area are guidelines that differ from one country to another or convey contradictory information, such as what is an acceptable preoperative hemoglobin level. Concerning anemia management, many European centers are aware of effective blood management techniques, but experts told Orthopaedics Today Europe strict surgical schedules can prevent delay of surgery to treat anemia.

What is more, no formal blood management training programs exist, resulting in a trend for new surgeons to transfuse blood more liberally than more experienced surgeons.

In total hip arthroplasty cases, Ove Furnes, MD, PhD, and colleagues at Haukeland University Hospital in Bergen, Norway, do not normally opt for blood reinfusion techniques, but may use cell savers for spine procedures. Image: Haukeland University Hospital

“Normally, for knee replacements, we use a tourniquet and we give 10 mg of tranexamic acid 10 minutes before the tourniquet and the same amount 10 minutes before the tourniquet is released,” Ove Furnes, MD, PhD, head of the Department of Orthopaedic Surgery at Haukeland University Hospital in Bergen, Norway, told Orthopaedics Today Europe. “Good hemostasis and good operating technique” should of course be part of standard practice, he said.

Furnes said his team’s blood management program is typical of those used at many Norwegian hospitals. For total hip arthroplasty (THA) and total knee arthroplasty (TKA), surgeons preoperatively screen hemoglobin levels to identify possible anemia cases and predict which patients may need postoperative transfusions. They typically do not use hemostatic agents or platelet gels except in special cases, relying instead on tranexamic acid to clear the surgery site peri-operatively and postoperatively, according to Furnes.

For large back surgeries, a cell saver is sometimes used, he said.

“There are several issues that need to be studied, such as if it is necessary to use drains postoperatively and how different regimes of antithrombotic prophylaxis and their timing affects blood management,” he said. “It is also a question if you should use a tourniquet and if you use it, when to release it.”

Practice based in tradition

Autologous blood donation and reinfusion is almost non-existent in Norway due to a good allogenic blood bank system. The risks associated with allogenic transfusion, including disease transmission and adverse reactions, are essentially eliminated in the country due to strict blood supply screening and an otherwise homogenous population, hence there is a lack of interest in self-donating blood, Furnes said.

But that is not the case with every country’s blood bank practices.

Athanasios Zacharopoulos, MD, in the Department of Orthopaedics at Greece’s General Hospital of Amfissa, said autologous blood donation has been a part of his TKA routine for the past 10 years.

“I mainly use a postoperative unwashed autologous blood reinfusion system,” he told Orthopaedics Today Europe. “This method resulted in a reduction of homologous blood reinfusion by 91% and of the cost by 76%. In my series, following the indications of the system strictly, I have not observed any adverse reactions after the reinfusion.

“I think there is an increased interest among orthopaedic surgeons about how to eliminate the need for homologous blood requirements.” — Athanasios Zacharopoulos, MD

“I think there is an increased interest among orthopaedic surgeons about how to eliminate the need for homologous blood requirements. Further knowledge of the alternative to allogenic transfusion methods and their efficacy can convince them to try it,” Zacharopoulos said.

Gilles Folléa, MD, PhD, executive director of the European Blood Alliance, an Amsterdam-based association of blood establishments in 23 countries, said such blood management discrepancies are common from country to country.

“At the moment, we could say there is no real European consensus on these issues,” he noted. “The organizations of blood transfusion services or blood transfusion activities are very different from country to country in Europe.”

Depending on the area of Europe, blood management and regulation can be either highly competitive or almost completely based in state organizations. Some countries, like Germany, have non-profit organizations competing with commercial companies whereas in the United Kingdom and France there is no competition due to a state monopoly on blood organizations, according to Folléa.

“You can envision one of the problems faced by many countries in Europe is that with the connections for the information between hospitals on one side, with the need for patients and the blood establishment on the other, this relationship is not well established,” Folléa said. “Sometimes it is very difficult to have a good connection between both and it is a [cause] of some issues. You could have a real difference in policies and outcomes from this.”

Preoperative screening

Whether surgeons prefer autologous or allogenic transfusion, busy schedules sometimes allow for little time to screen for anemia even though raising hemoglobin levels to accepted levels might reduce or eliminate the need for a transfusion altogether.

Øivind Jans, MD, a research fellow in the Surgical Pathophysiology section at Rigshospitalet in Copenhagen, said not treating anemia preoperatively is a major reason why many transfusions are done in his country.

“It is quite a new field in Denmark. But, the problem in the treatment of preoperative anemia is most controversial because often there is not enough time to do that,” he said.

Raising a patient’s hemoglobin prior to the scheduled surgery can be challenging and it is also a lot of work to reschedule the surgery, Jans noted.

A discrepancy also exists between the day and night shifts in hospitals. In some centers, junior doctors will transfuse more liberally because a nurse suggested it without the attending surgeon’s knowledge. This communication gap leads to surgeons not being aware of all transfusions performed because they did not initially authorize them, according to Jans.

While many “bloodless” surgery agents are available to control bleeding and keep hemoglobin levels in check, their cost effectiveness is debated. A prospective, randomized trial across six European countries by Weber and colleagues in the European Journal of Anaesthesiology showed epoetin alfa increased hemoglobin levels peri-operatively and helped prevent transfusion-related complications like infection. While there is a benefit to using the agent, Jans and others question its safety in normal surgery, preferring other bloodless agents such as low-cost tranexamic acid.

“Many [centers] now use tranexamic acid to avoid excessive bleeding or to reduce bleeding and some centers have started to get rid of drains,” Jans said.

Good scoliosis surgery technique

Geraldine Edge, PhD, FRCA, senior anesthetist at the Royal National Orthopaedic Hospital in London, said a conscientious surgeon manages blood loss by using a minimally invasive technique, which goes a long way to prevent blood loss, particularly in scoliosis surgery, an area in which her hospital specializes.

“Surgeons who do spinal surgery have a very high awareness of blood loss, especially the pediatric surgeons who are doing the big pelvic osteotomies and so on. They are very tuned in to blood loss and what a problem it can be,” Edge told Orthopaedics Today Europe.

“As an anesthetist, I think the single most important way of controlling blood loss is to have a surgeon who is aware.” — Geraldine Edge, PhD, FRCA

Although these spinal and pediatric surgeons have mastered effective approaches to blood loss, she said there is room for improvement in primary THA and TKA cases at her hospital; despite the predictability of blood loss during these “standard” procedures, no attempt is made to optimize patients’ hemoglobin by use of hematinics prior to surgery, she said.

“As an anesthetist, I think the single most important way of controlling blood loss is to have a surgeon who is aware. In terms of controlling blood loss, your surgery site is very important,” Edge said, stressing that in spine procedures care with patient positioning makes “a lot of difference to how much blood is being lost.”

Religious and cultural tolerance

One considerable challenge in blood management involves patients whose religion or culture prohibits blood transfusion. In general, European orthopaedists will use cell salvage in such cases when significant blood loss is expected. However, the idea of a system that has no discontinuity between a patient’s body and the blood is sometimes still not enough to convince patients to proceed with a procedure that may be life-threatening.

“Some patients just refuse [a procedure] empirically if it is going to be associated with blood loss,” Edge explained, saying that sometimes leaves trying to convince them to go through with it as the only option.

When consulting with the patient proves unconvincing, she said her hospital has a Jehovah’s Witness liaison group that reviews with the patient the system used and it has proven effective in persuading many patients to proceed with the needed treatment.

International guidelines

Folléa told Orthopaedics Today Europe, “To me, the biggest problem is the differences [in blood loss] between surgical operations, showing you could educate clinicians and surgeons to do better in order to reduce the need for blood.”

To this end, the health authority section of the Council of Europe, a 47-country effort focused on the wellness of European citizens, has enlisted a community of experts on transfusion to identify and analyze the best blood supply management practices in Europe.

“We would like to identify good practices in blood supply management processes in order to organize a meeting to share the results of the survey and really try to write a manual of good practices of blood supply management,” said Folléa, who is a chairperson for a blood management research group.

More recently, groups, like the Network for Advancement of Transfusion Alternatives, founded in Austria, hold open symposiums on the subject to educate doctors in proper blood management in everyday surgery.

“There is a real movement to assess and benchmark what the practices are today, what could be the best practices, and how to disseminate good practices in blood management, at least at the European level, but also [globally],” Folléa said. – by Jeff Craven

References:

• www.coe.int
• www.nataonline.com
• Weber EWG, Slappendel R, Hémon Y, et al. Effects of epoetin alfa on blood transfusions and postoperative recovery in orthopedic surgery: the European epoetin alfa surgery trial (EEST). Eur J Anaesthesiol. 2005;22(4):249-257.

• Geraldine Edge, PhD, FRCA, can be reached at the Department of Anesthesia, Royal National Orthopaedic Hospital, 45 Bolsover St., Greater London, United Kingdom; +44 208 909 5560; email: geraldine.edge@rnoh.nhs.uk.
• Gilles Folléa, MD, PhD, can be reached at the European Blood Alliance, 17, Rue de Tabellion, Brussels, Belgium 1050; +31 6 228 09 178; email: g.follea@sanquin.nl.
• Ove Furnes, MD, PhD, can be reached at Jonas Liesvei 65, 5021 Bergen, Norway; +47 55 97 56 80; email: ove.furnes@helse-bergen.no.
• Øivind Jans, MD, can be reached at Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark; +45 21 68 80 12; email: oeivind.jans@rh.regionh.dk.
• Athanasios Zacharopoulos, MD, can be reached at General Hospital of Amfissa, Oikismos Drosochoriou, 33100 Amfissa, Greece; +30 22 65 03 51 10; email: docthaz@otenet.gr.
• Disclosures: Edge, Folléa, Furnes, Jans and Zacharopoulos have no relevant financial disclosures.

Is reintroducing a patient’s blood part of your blood management practice? Why?

Better TKA techniques available

Oscar Ares

Currently, we do not use intraoperative or postoperative blood salvage or autotransfusion, as there are other blood-saving techniques that have reduced our transfusion rate.

One of the reasons against using these blood savers is that the drain volume increases due to pressure exerted by aspiration. Moreover, its use does not show a good cost/benefit relationship and its use may have adverse reactions when receiving the blood as it has inflammatory factors, hypercoagulability and an increase in interleukin-6. There is a reported case of tracheal edema post-reinfusion of the recovered blood.

Preoperative autotransfusion, in my experience, is a technique that I no longer use for several reasons. Firstly, there is an imbalance between the removed bags and the transfusional ones, ending in an expensive and ineffective measure. Secondly, the emergence of intravenous iron and erythropoietin (EPO) has decreased the need for autotransfusion to patients for whom it is difficult finding compatible blood.

Correction of anemia preoperatively by stimulation with EPO or iron administration is important as preoperative hemoglobin concentration is one of the utmost important predictive factors for autologous blood transfusion.

Routine use of tranexamic acid preoperatively and postoperatively has been the key element in our decision making. Studies have shown its administration in TKA significantly reduces blood by up to 50% and diminishes transfusion requirements without increasing the risk of thromboembolic events. Both in THA and spinal surgery, administering tranexamic acid prophylactically reduces intraoperative blood loss without increasing the incidence of thromboembolic complications.

In conclusion, I believe there are other techniques in addition to autotransfusion and blood recoveries that enable us to reduce the transfusion rate and maintain a correct blood volume.

Oscar Ares, MD, PhD, is an orthopaedic surgeon specializing in knee surgery at Hospital Clinic Barcelona and Hospital Quiron Barcelona in Barcelona.
Disclosure: Ares has no relevant financial disclosures.

Autotransfusion inefficient in THA

Vijay Kumar

Retransfusion of a patient’s blood is not a part of our blood management policy.

Our practice of blood management is the use of tranexamic acid which is safe, efficient and cheaper than other modalities. Tranexamic acid reduces the blood loss and transfusion requirement by 50% without increasing the risk of deep vein thrombosis. Autotransfusion has the disadvantage of lowering the patient’s hemoglobin as a result of phelobotomy-induced anemia, thereby resulting in an increase in the overall rate of transfusion postoperatively. In addition to adding to the cost, a high rate of wastage has also been reported with autotransfusion.

Blood salvage and reinfusion is only useful in cases with at least 2 units to 3 units of blood loss and may even cause coagulopathy if given in large volume, as it lacks platelets and clotting factors. The reinfusion of lysed red blood cells may also cause hemoglobinuria resulting in renal insufficiency.

Blood salvage also requires the use of expensive equipment, such as cell savers.

Tranexamic acid is an economical and safe option for blood management.

Vijay Kumar, MS, is an orthopaedic surgeon at the All India Institute of Medical Sciences in New Delhi, where he focuses on joint replacement.
Disclosure: Kumar has no relevant financial disclosures.