AAOS Comprehensive Orthopaedic Review

Section 2 - General Knowledge

Chapter 19. Blood Management

I. Blood Management Programs

A. Definition of blood management—Proactive processes, techniques, drugs, or medical devices that reduce the need for allogeneic blood when used in an efficient, effective and timely manner.

 

B. Principles

 

1. Use of evidence-based transfusion guidelines to reduce variability in transfusion practice

 

2. Use of multidisciplinary teams to study, implement, and monitor local blood management strategies

 

C. Goals

 

1. Ensure that each blood product that is transfused is appropriate.

 

2. Ensure that blood-related resources are used efficiently and effectively.

 

D. Hospital responsibilities—By developing and implementing comprehensive blood management programs, hospitals can promote safe, efficient, and clinically effective blood utilization practices for the benefit of the health system, its patients, and the local community.



II. Issues in Blood Banking

 

A. Availability and use

 

1. More than 29 million units of blood components were administered in the United States in 2004.

 

2. As the donor pool continues to decrease, there are real concerns that in the near future, demand will outstrip supply.

 

3. Blood use is suboptimal in many hospitals because of poor training and inadequate oversight, review, and monitoring of transfusion practices.

 

   *Timothy J. Hannon, MD, MBA, or the department with which he is affiliated has received miscellaneous nonincome support, commercially-derived honoraria, or other nonresearch-related funding from Bayer, Medtronic, and Ortho Biotech. Jeffrey L. Pierson, MD, is a consultant for or an employee of Zimmer.

 

4. Blood substitutes currently are not US Food and Drug Administration (FDA) approved given the lack of safety and efficacy data.

 

B. The decision to transfuse

 

1. Often clouded by myths, misconceptions, and emotions, and not supported by good medical science

 

2. Generalized lack of compliance with appropriate transfusion guidelines

 

3. Transfusion practices vary widely among institutions and among individual physicians within the same institution.

 

C. Risks and benefits

 

1. Although the blood supply is the safest it has ever been, transfusion of blood components remains a high-risk procedure that results in some degree of harm to all patients.

 

2. The benefits of transfusion, especially the use of red cells, are not well elucidated. Few, if any, well-controlled studies demonstrate improved outcomes with red cells.

 

a. In the landmark 1999 Transfusion Requirements in Critical Care (TRICC) trial, a restrictive strategy of red cell transfusions (Hgb 7.0) was at least as effective and possibly superior to a more liberal strategy (Hgb 9.0-10.0) with the possible exception of patients with acute coronary syndromes.

 

b. A 2004 study by cardiologists at Duke University questioned the benefit of transfusions in high-risk cardiac populations.

 

3. Bacterial contamination of platelets is one of the leading causes of transfusion-related morbidity and mortality, with a frequency of 1:2,000 to 3,000 transfusions.

 

4. Transfusion of blood products to the wrong patient is also a leading risk, with the alarming frequency of 1:12,000 to 1:19,000 units transfused.

 

5. Death occurs in 1:600,000 to 1:800,000 transfusions.

 

6. Prolonged storage of blood products (allogeneic and autologous) leads to a progressive decline in product quality and linear increases in debris and inflammatory mediators.

 

D. Costs

 

1. Blood product prices more than doubled between 2001 and 2007.

 

2. Within hospitals, the procurement, storage, processing, and transfusion of blood products involves an array of expensive resources that include laboratory supplies, pharmaceuticals, and medical devices, as well as significant technician and nursing time (

Figure 1).

 

3. Resource utilization in the administration of blood products to patients results in a three- to fourfold increase in the total cost of blood beyond the base cost of their acquisition.

 

4. Accounting for adverse events such as increased length of stay and infection rates may make the total cost of allogeneic transfusion as high as $2,000 per unit.

 

5. Cost of blood products and processing must be considered when comparing allogeneic transfusions with transfusion alternatives.

 

[Figure 1. Transfusion costs by resource category. Direct material costs (19%) reflect the costs of acquiring blood products and supplies as a percentage of total cost. Total cost of an outpatient transfusion accounting for all resource categories was $677 to $752 in 2004 dollars.]

III. General Blood Management Strategies

A.

General strategies and principles are outlined in

Tables 1 and

2.

B.

Preoperative preparation and planning (Table 1)

 

1. Preoperative planning is essential to the safe and optimal management of surgical patients.

 

2. Early identification of high-risk patients amenable to strategies to modify those risks can improve patient outcomes and improve overall resource utilization by reducing adverse events.

 

3. Universal predictors for transfusion requirements

 

a. Type and complexity of surgery

 

b. Preoperative anemia

 

c. Preexisting coagulopathy

 

[Table 1. Orthopaedic Blood Management Strategies]

[Table 2. Blood Management Principles]

[

Figure 2. Blood management algorithm for primary unilateral total hip and knee arthroplasty illustrating patient-specific recommendations. The preoperative hemoglobin is the hemoglobin before the patient enters the algorithm. The baseline hemoglobin is the hemoglobin at the time of surgery. THA = total hip arthroplasty; TKA = total knee arthroplasty.]

4. Improving preoperative hemoglobin levels is the single best strategy for patients at risk of needing an allogeneic blood transfusion after orthopaedic surgery.

 

a. Figure 2 is an algorithm for the use of erythropoietin in selected patients.

 

b. Established protocols should be used for discontinuation of drugs such as aspirin, coumadin, and clopidogrel, as well as certain herbal supplements that increase bleeding.

 

5. Anemia management protocols are essential to blood management programs because they increase red cell mass in anemic patients, reducing or eliminating the need for allogeneic blood during high blood loss surgeries.

 

6. Formal protocols for preoperative testing of hemoglobin for major blood loss surgeries and coagulation status testing in certain patient populations should be in place.

 

D.

Predonated autologous blood

 

1. Causes iatrogenic anemia that is treated with a return of the predonated blood, without a net benefit to the patient.

 

2. Storage of autologous blood leads to a progressive decline in the quality of the red cells and increase in inflammatory mediators.



IV. Perioperative Blood Management Strategies

A. Laboratory-related considerations

 

1. Measured laboratory values are needed to make evidence-based transfusion decisions.

 

2. Absence of timely information often leads to excessive or improper selection of blood products, unnecessarily exposing patients to harm.

 

3. Hemoglobin or hematocrit testing should be readily available perioperatively.

 

4. Coagulation and platelet function testing are useful in complex cases.

 

B. Technique-related considerations

 

1. After adequate patient preparation, the next most important orthopaedic blood management strategy is meticulous yet efficient surgical technique.

 

2. Longer surgical times are strongly correlated with complications and blood loss in major orthopaedic and spine surgery.

 

3. Use of regional anesthesia can lower blood loss, probably through the combined benefits of a slightly lowered blood pressure and good postoperative pain control.

 

4. Use of controlled hypotension is controversial and has fallen into disfavor because of marginal blood-sparing benefits and a greatly increased medicolegal risk if perioperative adverse events occur.

 

5. Acute normovolemic hemodilution is not widely practiced and not recommended.

 

a. The theoretical benefit comes from patients bleeding "thinner" blood through the early withdrawal then late return of autologous blood in the operating room.

 

b. With good patient selection and proper technique, other blood-sparing effects are available for patients who have large amounts of blood withdrawn and subsequently lose large amounts of blood intraoperatively.

 

C. Other patient-related considerations

 

1. Proper patient positioning to reduce venous bleeding

 

2. Monitoring and maintenance of patient temperature because even mild hypothermia (35°C) greatly increases bleeding time and blood loss because of the relationship between temperature and the clotting cascade.

 

D. Use of perioperative autotransfusion ("cell saver")

 

1. This technique is safe and cost-effective when performed by properly trained and proficient personnel using properly maintained and certified devices.

 

2. It should be used only when the collection and return of one unit or more of red blood cells is likely.

 

E. Limiting early postoperative blood loss

 

1. Early postoperative blood loss often is the result of fibrinolysis, followed by a hypercoagulable state within 8 to 16 hours.

 

2. Perioperative use of antifibrinolytics such as tranexamic acid, epsilon aminocaproic acid, and aprotinin have demonstrated dramatic reductions in postoperative blood loss (< 50%) without an apparent increase in thromboembolic events.

 

3. Aprotinin is used extensively in cardiac surgery and has additional anti-inflammatory properties, but its orthopaedic use may be limited by costs (~ $800 per patient) and the risk of adverse events such as hypersensitivity reactions and renal dysfunction in certain patients.



V. Postoperative Blood Management Strategies

A.

The key to blood management is the maintenance of endogenous red cell mass.

B.

Postoperative transfusion decisions should be based on measured laboratory values using evidence-based protocols.

C.

Major orthopaedic surgery is associated with large amounts of blood loss, with a 46% reported rate of allogeneic and autologous transfusions after primary hip and knee arthroplasty.

D.

Most postoperative symptoms in orthopaedic patients that are attributed to anemia are more causally related to volume deficits from postoperative bleeding. Aggressive but well-monitored volume replacement generally is sufficient to allow rehabilitation and timely discharge of postoperative patients with hemoglobin levels in the 7 to 8 g/dL range.

E.

Wound drainage reinfusion systems often are used for postoperative blood conservation.

1. These devices work by drawing shed blood from the wound under low vacuum into a sterile collection reservoir and returning the blood within the first 4 to 6 hours after surgery after it is passed through a filter.

 

2. It is our expert opinion that the return of unwashed shed blood is not a sound practice, and washed cell reinfusion devices are strongly recommended.

 

a. Blood collected from surgical wounds typically has a low hematocrit and is usually of poor quality from surgical debris and harmful inflammatory mediators.

 

b. Common complications associated with retransfusion of shed blood include systemic inflammatory response syndrome (SIRS), transfusion-related acute lung injury (TRALI), and increased postoperative bleeding as a result of fibrin degradation-induced disseminated intravascular coagulation (DIC).

 

c. Simple filtration systems are insufficient to remove cytokines and fibrin degeneration products; therefore, no "safe" amount of this blood can be returned.

 

d. If shed blood is of sufficient quantity to be retransfused, it should be washed on a certified autotransfusion device that is operated by qualified personnel.

D.

As with intraoperative transfusion decisions, postoperative transfusions should be based on measured laboratory values and evidence-based protocols.

 

Top Testing Facts

1. Optimal blood management constitutes proactive processes, techniques, drugs, or medical devices that reduce the need for allogeneic blood when employed in an efficient, effective, and timely manner.

 

2. Blood use is suboptimal in many hospitals because of poor training and inadequate oversight, review, and monitoring of transfusion practices.

 

3. Although the blood supply is the safest it has ever been, transfusion of blood components remains a high-risk procedure that results in some degree of harm to all patients.

 

4. Storage of blood (allogeneic and autologous) results in a progressive decline in the quality of the red cells and an increase in inflammatory mediators.

 

5. Formal protocols for preoperative testing of hemoglobin for major blood loss surgeries and coagulation status testing in certain patient populations are important for early identification and intervention.

 

6. A core element of perioperative blood management is the use of measured laboratory values to make evidence based transfusion decisions. Absence of timely information often leads to excessive or improper selection of blood products, unnecessarily exposing patients to harm. There should be ready availability of hemoglobin or hematocrit testing in the perioperative period. Coagulation and platelet function testing also are useful in complex patients.

 

7. After adequate patient preparation, the next most important orthopaedic blood management strategy is meticulous yet efficient surgical technique.

 

8. Postoperative transfusion decisions also should be based on measured laboratory values using evidence-based protocols.

 

9. Major orthopaedic surgery is associated with large amounts of blood loss, with a 46% reported rate of allogeneic and autologous transfusions after primary hip and knee arthroplasty.

 

10. Many symptoms in postoperative orthopaedic patients attributed to anemia are more causally related to volume deficits from postoperative bleeding. Aggressive but well-monitored volume replacement is generally sufficient to allow rehabilitation and timely discharge in postoperative patients with hemoglobin levels in the 7 to 8 g/dL range.



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