One of the main goals of blood management for patients undergoing THA is to identify those at high risk for bleeding and to reduce the need for transfusion with allogenic blood. In this study we retrospectively reviewed revision hip arthroplasties to assess the effectiveness of the Blood Utilization Program, use of tranexamic acid and to determine the variables associated with a higher risk of allogenic transfusion in these patients.
Our study is limited by several factors. First, patients not included in the Blood Utilization Program were admitted from the emergency room or had an urgent referral for a periprosthetic fracture or periprosthetic infection; consequently, there was no time for their preoperative assessment by the Blood Utilization Program. In contrast, all of the patients in the Blood Utilization Program were having elective surgery, and had ample time to attend the Blood Utilization Program. Therefore the non-BUP patients would not be an appropriate control group as the indications for surgery are different. We overcame this issue by performing a logistic regression analysis for all patients in this study requiring an allogenic transfusion. Second, 95% of the patients not in the Blood Utilization Program had a preoperative hemoglobin level of 130 or less, compared to only 29% of the patients in the Blood Utilization Program. Since the non-Blood Utilization Program group is dominated (95%) by patients with a preoperative hemoglobin level of 130 or less, this could contribute to the importance of preoperative hemoglobin in the logistic regression model.
To our knowledge, this is the first study in the literature that reviews a comprehensive blood management strategy in patients undergoing revision hip arthroplasty patients starting with a preoperative assessment including use of erythropoietin and hematinics, intraoperative use of tranexamic acid, cell salvage as well as postoperative use of hematinics. No single study has looked at all of these variables in any one population.
Bierbaum et al. reported a 46% rate of allogenic and autologous transfusion in a series of 9482 patients managed with total joint arthroplasty . Autologous transfusion is a relatively safe and effective option for these patients, but the collection and transfusion of autologous blood carry risks including compartment syndrome, bacterial contamination, febrile nonhemolytic and septic reactions, phlebitis, and clerical error [20, 28]. Also, predonation of autologous blood has been extremely inefficient, with wastage rates ranging from 40% to 56% [3, 14]. For these reasons, autologous transfusion has been mostly abandoned at our center.
Recombinant human erythropoietin alpha is considered an effective preoperative treatment for increasing preoperative hemoglobin levels, and was administered to the patients in the Blood Utilization Program based on their preoperative hemoglobin levels and the time remaining between the Blood Utilization Program referral date and surgery date. Three major, double-blind, placebo-controlled studies involving 724 patients, with hemoglobin levels between 100 and 130, having major elective orthopaedic surgery [6, 9, 10] showed that treatment with 300 IU/kg epoetin alfa per day, for at least 14 days, beginning 10 days before surgery and continuing until the third or fourth day after surgery, decreased the number of patients requiring transfusion compared with patients given a placebo. Our patients in the Blood Utilization Program not using preoperative erythropoietin had no increased risk of transfusion.
The preoperative hemoglobin concentration is a strong predictor of perioperative transfusion and is often used to discriminate between patients at higher and lower risk for transfusion [3, 11, 24]. Several other factors reportedly influence perioperative blood loss in patients undergoing hip arthroplasty including gender, age, physical status of the patient, hypertension, body mass index, coagulation factors, type of anesthesia, and surgical procedure [1, 7, 8, 13, 19, 21, 25, 26]. Walsh et al.  reviewed 1035 cases of THA and reported the most important and consistent predictors of the requirement for a blood transfusion was advanced age and the use of low molecular weight heparin for DVT prophylaxis. Our data suggest that female gender, increased BMI, low preoperative hemoglobin, no intraoperative use of tranexamic acid, revision of acetabular implant, and increased operative time independently increased the need for transfusion.
Our data suggest referral to our center’s Blood Utilization Program did not reduce the transfusion rate or transfusion amount. However, in patients referred to the Blood Utilization Program, intraoperative use of tranexamic acid was associated with reduced transfusions; the use of preoperative erythropoietin did not influence transfusion rates nor did the use of preoperative oral iron supplements. Therefore to further increase the relevance of the blood utilization program, the guidelines for patients undergoing revision hip arthroplasty need to be redefined. Also, the use of preoperative erythropoietin in these patients needs further research.
We thank Daphné Savoy for her assistance in the preparation of this manuscript.
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