Blood management strategies may avoid the need for transfusions following THA

Pre-, intra- and postoperative interventions can be customized to patients' needs and wishes.

A steady rise in the number of blood transfusions coupled with national shortages in the blood supply have caused some surgeons to reconsider their blood management strategies for patients undergoing total hip arthroplasty.

"Blood transfusion is a widely accepted way of treating severe perioperative anemia and acute blood loss," said Bernard N. Stulberg, MD, of Cleveland. "However, we are now reaching a time where there has been a steady increase in the use of blood, 6% since 1994, and there are now significant national shortages."

Stulberg told the audience at the Current Concepts in Joint Replacement winter meeting that in 2006, the full cost of a transfusion rose to more than $1,000 including aquisition and administrative costs. The cost, plus the negative effects of transfusions are even more reasons why surgeons should adopt blood management strategies. "In your environment, a blood management strategy should be a coordinated approach to the management of blood loss in the perioperative period of an elective procedure," he said.

Other benefits of this type of strategy: optimized patient recovery, diminished infection risk, increased postop energy level, and quicker recovery. "So you need to pay attention to this," Stulberg said.

Overall, plans he said that are "in" include: patient-specific blood management strategies, coordinated programs, preoperative assessments, blood salvage, tissue-sealing and patient-specific transfusion triggers. What's out: routine autologous donation for all patients, fixed transfusion triggers and uncontrolled application of blood transfusion.

Stulberg advocates patient-specific plans. Deciding on a transfusion should not be based on a specific number, such as the 10/30 rule, where you transfuse whenever the patient's hemoglobin level fell below 10 g/dl, but rather on the patient's physiologic response to the anemia. He said that transfusion risk has been evaluated in many ways, but that the most consistent predictor of a need for transfusion is a preoperative hemoglobin level below 13.

Preoperative plans would include using erythropoietin and autologous donation, which would be good for at-risk populations.

Intraoperative strategies include conscientious tissue handling and selecting the most appropriate type of component - cemented devices will loose less. Minimally invasive techniques may also help. "but you need to measure that," Stulberg said.

Devices such as the Orthopat [Haemnetics] cell salvage system can also help intraoperatively with at-risk populations, such as Jehovah's Witnesses who allow recycling.

"You need to realize that in a patient-specific treatment strategy, there are certain populations that you may have to modify your strategy for," Stulberg said. "The patient with cardiopulmonary compromise is going to have a higher transfusion trigger. With the Jehovah's Witness population, you are going to be more aggressive about some of these strategies."

For more information:
Stulberg BN. Blood management issues: What's in and what's out. Paper #34 Presented at the 23rd Annual Current Concepts in Joint Replacement Winter 2006 Meeting. Dec. 13-16, 2006. Orlando, Fla.