A Restrictive Use of Both Autologous Donation and Recombinant Human Erythropoietin Is an Efficient Policy for Primary Total Hip or Knee Arthroplasty

Abstract

A limitation of preoperative autologous blood donation (PABD) in nonanemics and the use of recombinant human erythropoietin (EPO) in anemics (baseline hematocrit [Hct] < or = 39%) could be an efficient approach of the cost-benefit ratio of transfusion during primary total hip (THA) or knee (TKA) arthroplasties. We evaluated the consequences on transfusion rates and costs of two different applications of a transfusion policy based on personal requirements during primary THA or TKA. This quality assurance observational study compared two prospective successive time periods; each included successive patients treated by the same medical team and standardized care. In Study 1 (n = 182), PABD was indicated if there were insufficient estimated red blood cell reserve and a life expectancy > or = 10 yr, no use of EPO, and identical criteria for any transfusion. Because this policy led to a 50% allogeneic transfusion rate when baseline Hct < or = 37% and autologous blood wastage in the nonanemics (baseline Hct > 39%), 2 refinements were introduced in Study 2 (n = 708): EPO without PABD when baseline Hct < or = 37%, and life expectancy > or = 10 yr, and avoidance of PABD in nonanemics. This novel care induced a marked decrease in transfusion rates (respectively, from 41% to 7%, P < 0.0002, in nonanemics; from 58% to 27%, P < 0.003, in anemics; and from 43% to 12%, P < 0.0001, overall), with no change in allogeneic transfusion (10%) and discharge Hct, and a 39% financial savings. This saving effect is a result of the suppression of PABD in nonanemics, who represent 75% of this surgical population. Although erythropoietin is expensive, it can be used with cost savings in selected patients because the overall cost of transfusion is reduced.

Efficacy of Extramedullary Femoral Component Alignment Guide System for Blood Saving after Total Knee Arthroplasty

“…Accordingly, a blood transfusion is often required after TKA. In an attempt to reduce the adverse effects of blood transfusion, many studies have provided various methods, including preoperative autologous donation3-5), use of the call saver19) and fibrinogen concentrates20), subcutaneous suction drainage6), drain clamping7), hypotensive anesthesia8), and other methods17-21).…”

“…Accordingly, continuous efforts have been made to avoid complications associated with allogeneic blood transfusion, which has led to the invention of blood saving strategies including preoperative autologous donation3-5), treatment of preoperative anemia using oral iron therapy, subcutaneous drainage6), drain clamping7), and hypotensive anesthesia8). Lower extremity alignment is one of the paramount factors determining the long-term success of TKA9-11).…”

Nonanemic Patients Do Not Benefit from Autologous Blood Donation before Total Hip Replacement

“…Faris and coworkers demonstrated that erythropoietin administered before elective orthopedic surgery can reduce allogeneic transfusions as well [10]. Other studies have shown that erythropoietin may reduce the need for allogeneic blood, raise preoperative hemoglobin, and decrease the need for autologous blood donation [5,12,13,16]. Cushner retrospectively compared PABD to epoetin alpha in anemic patients undergoing total knee arthroplasty.…”

Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications

“…Total knee replacement surgery, because of its technical features (reduced time of operation, use of tourniquet), actually involves controlled perioperative blood loss. Some Authors have recently questioned the utility of a predeposit programme in reducing the likelihood of allogeneic transfusions in patients undergoing primary unilateral TKA [13][14][15][16][17].…”