Techniques for reducing allogeneic transfusion rates

George Allen

Transfusion

July 2006

Substantial blood loss occurs during total knee replacement surgery, with 20% to 30% of these patients requiring allogeneic blood transfusion. Allogeneic blood is scarce and becoming increasingly expensive. In addition, allogeneic blood transfusion is not without risk for patients undergoing orthopedic procedures because it may increase the rate of fluid overload, transfusion-related acute lung injury, or postoperative infection.

A recent meta-analysis concluded that preoperative autologous blood donation and perioperative cell salvage decrease the need for allogeneic blood transfusion in orthopedic surgery. It can be inferred that adopting a transfusion protocol may reduce the relative risk for allogeneic blood transfusion by 25% to 30%, and therefore, adopting a transfusion protocol must be the first strategy to include in a blood-saving program. Alternatively, it is well known that preoperative hemoglobin (Hb) level is one of the strongest predictors of the need for postoperative allogeneic blood transfusion after total knee replacement and that stimulation of red blood cell production may reduce the requirement for allogeneic blood transfusion in patients with mild anemia. Perioperative administration of iron sucrose, with or without recombinant human erythropoietin (rHuEPO), also is known to be effective at reducing the allogeneic blood transfusion rate for hip fracture repair. The purpose of this study was to evaluate the effectiveness of implementing a restrictive transfusion protocol (ie, initiate transfusion only when Hb is less than 80 g/L) plus perioperative stimulation of erythropoiesis, with or without postoperative blood salvage, in reducing the requirements for allogeneic blood transfusion in patients undergoing total knee replacement. (4)

From March 2003 to June 2005, patients scheduled for elective total knee replacement at a university hospital in Spain were enrolled in the study. Patients were excluded if they had hematologic diseases, coagulation disorders, or hepatic or renal diseases; if they were undergoing anticoagulant therapy; if they had a known infection or malignancy at admission; or if they had donated autologous blood preoperatively. Demographic and clinical data were collected, including age, gender, height, weight, type of procedure, perioperative Hb concentration, transfusion rate, postoperative noninfectious and infectious complications, in-hospital mortality, and length of hospital stay. All patients underwent procedures performed by the same surgical team using standardized anesthesia, antibiotic and anti-thrombotic prophylaxis, and postoperative analgesia.

Patients in group A received two doses of 200 mg iron sucrose IV--one dose 24 hours before surgery and the second dose 24 hours after surgery. Patients with Hb levels of less than 130 g/L also received a single dose of 40,000 international units of rHuEPO 24 hours before surgery. This protocol also was applied to patients in group B; however, patients in group B also received postoperative unwashed shed blood (ie, blood salvage) if their Hb at admission was less than 130 g/L. At the end of the surgical procedure, unwashed shed blood was collected and returned within the first six hours postoperatively.

Postoperative transfusion was indicated in both groups when the patient's Hb level fell below 80 g/L or when the patient presented with symptoms of acute anemia (eg, hypotension, tachycardia, tachypnea, dizziness, fatigue). Full blood counts were determined preoperatively and one and seven days after surgery. Hemoglobin level also was determined preoperatively and on postoperative days one and two. Additionally, iron metabolism variables were measured preoperatively and on postoperative day seven. Iron deficiency was defined as a serum ferritin level of less than 30 nanograms (ng)/mL, and functional deficiency was defined as a ferritin level of less than 50 ng/mL and a C-reactive protein level of 5 mg/L. Common statistical procedures, including mean, standard deviation, Pearson's chi-square tests, and multivariate logistic regression analysis techniques, were used to analyze the data.

Findings. Three hundred twelve consecutive patients were enrolled in the study (n = 139 patients in group A and n = 173 patients in group B). There were no significant differences between the groups in regard to age, gender, weight, height, type of procedure, preoperative Hb levels, or postoperative complications.

Before surgery, 24% of patients (ie, 33) in group A and 19% of patients (ie, 33) in group B had a Hb level lower than 130 g/L and received iron sucrose plus rHuEPO. In group B, these patients also were assigned to receive postoperative blood salvage therapy. One hundred six patients in group A and 140 patients in group B received only IV iron sucrose. There were no adverse effects associated with administration of iron sucrose, rHuEPO, or unwashed shed blood, and overall, only 13 patients (ie, 4%) received allogeneic blood transfusions. Stimulation of erythropoiesis appeared to be more pronounced in those patients receiving rHuEPO (P < .05). There were no differences between the groups in postoperative complications, but length of hospital stay for patients with a preoperative Hb level lower than 130 g/L was shorter for patients in group B (P < .05).

Clinical implications. The results of this study revealed that a blood-saving protocol consisting of a restrictive transfusion trigger plus perioperative administration of IV iron sucrose with or without rHuEPO appears to be effective at reducing the need for allogeneic blood transfusion in total knee replacement surgery. Perioperative nurses should understand, however, that additional studies are warranted to determine which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment to avoid needing allogeneic blood transfusion.

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REFERENCES

(1.) Tejirian T, DiFronzo LA, Haigh PI. Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanyalysis. J Am Coil Surg. 2006;203:729-734.

(2.) Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg. 2006; 141:659-662.

(3.) Debreceni G, Meggyesi R, Mestyan G. Efficacy of spray disinfection with a 2-propanol and benzalkonium chloride containing solution before epidural catheter insertion--a prospective, randomized, clinical trial. Br J Anaesth. 2007;98:131-135.

(4.) Cuenca J, Garcia-Erce JA, Martinez F, Perez-Serrano L, Herrera A, Munoz M. Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. Transfusion. 2006;46: 1112-1119.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

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