Autologous blood transfusion in total hip arthroplasty

Journal of Orthopaedic Surgery, Dec 2004 by Yamamoto, K, Imakiire, A, Masaoka, T, Shinmura, K

ABSTRACT

Purpose. To determine the possibility of avoiding homologous blood transfusion during total hip arthroplasty, and to clarify the problems associated with autologous blood transfusion.

Methods. A total of 253 patients received autologous blood transfusion during total hip arthroplasty between April 1990 and December 2000. Patients were assessed for the volume of haemorrhage during surgery, possibility of avoidance of homologous blood transfusion, and the disposal of autologous blood.

Results. There were no significant differences in the mean volume of haemorrhage among different underlying diseases. The mean total volume of haemorrhage was 2039 (standard deviation, 992) ml in revision surgery and 1673 (717.3) ml in primary surgery (p

Conclusion. Combined use of the preoperative blood pooling and intra-operative recovery systems is effective for avoiding homologous blood transfusion.

Key words: arthroplasty, replacement, hip; blood transfusion, autologous

INTRODUCTION

Owing to advancements in blood transfusion, surgery has evolved considerably in recent years. However, problems associated with homologous blood transfusion, such as transmission of infections and immunological side-effects, have attracted attention. Because blood transfusion is a type of transplantation, autologous blood transfusion has been recommended to prevent such problems. This technique of using preoperatively pooled blood for autologous blood transfusion has been widely practised, particularly for elective surgery.

For total hip arthroplasty (THA), homologous blood transfusion has increasingly been avoided, while autologous blood transfusion has gained popularity. According to reports from various institutions,1-5 the avoidance rate for homologous blood transfusion for THA has been 90% or higher in the past several years.

At the Department of Orthopedic Surgery, Tokyo Medical University, we have been using autologous rather than homologous blood transfusion for THA since April 1990. However, we have not completely avoided homologous blood transfusion. In this report, we discuss our experience of blood transfusion during THA and identify ways of increasing the avoidance rate of homologous blood transfusion, as well as problems associated with autologous blood transfusion.

METHODS

Between April 1990 and December 2000, a total of 253 patients underwent THA with autologous blood transfusion at the Department of Orthopedic Surgery, Tokyo Medical University. The patients consisted of 56 men and 197 women, whose mean age at surgery was 60.3 (standard deviation [SD], 11.5; range, 32-81 years). Of the 253 patients, 202 had osteoarthrosis (OA), 1.3 had rheumatoid arthritis (RA), and 38 had avascular necrosis of the femoral head (ANF). In all, 204 patients and 49 patients underwent primary and revision THA, respectively. Cement was used in 79 cases of primary THA, and bone grafting was used for 91 cases. Of the 49 patients undergoing revision THA, 35 underwent total replacement, 8 underwent replacement of the cup side alone, 3 underwent replacement of the stem side alone, and 3 underwent replacement of the polyethylene (PE) liner alone. A posterolateral approach was used in surgery; general anaesthesia was administered to all patients, and no anticoagulants were used postoperatively.

At our institution, predeposit autologous blood transfusion has been adopted since April 1990, and intra-operative autologous blood transfusion using a cell saver (Cell Saver 4; Haemonetics Co., Braintree [MA], US) has been used since February 1994 (Fig. 1). For both primary and revision THA, the minimum target of blood collection is 800 ml. Whenever possible, 1200 ml of blood is pooled, and the whole-blood liquefaction preservation method using citrate-phosphate-dextrose preservative solution is adopted for all cases. The preoperative blood pooling system alone was used in 81 (32%) patients, the intra-operative recovery system alone in 24 (9%) patients, and combination of both systems in 148 (59%) patients. Blood collection for autologous blood transfusion was based on the standards of the Japanese Society of Blood Transfusion.

The current range of indications for blood collection is wide: blood is collected, if possible, even from patients with a haemoglobin (Hb) level of 100 g/l. A total of 400 ml of blood is collected once a week. Erythropoietin at 12 000 U per dose is administered at each blood collection, and iron and iron salts are administered to all patients. Erythropoietin is administered before blood pooling for patients who have a serum Hb level of 130 g/l or lower. When the Hb level increases to 140 g/l or above, or when the haematocrit increases to at least 42% after the start of blood pooling, administration of erythropoietin is discontinued or delayed until the next blood collection date.

Postoperative homologous blood transfusion is initiated when the serum Hb becomes 80 g/l or lower in patients older than 70 years, or when the serum Hb becomes 70 g/l in younger patients. In younger patients, the Hb level is monitored, and the blood pressure, pulse, and preoperative Hb level are also monitored before homologous blood transfusion starts. For patients with RA, the preoperative Hb level is monitored before homologous blood transfusion starts, because these patients show a disease-specific tendency towards developing anaemia.