Réduction des transfusions sanguines allogènes grâce à un protocole basé sur le risque dans les cas d’arthroplastie avec prothèse totale

Abstract

Purpose To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood. Methods We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 gÁL -1 were given erythropoietin, dosed by weight. Subjects with Hb 130-139 gÁL -1 underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb [139 gÁL -1 received no special intervention, unless they were aged[70 yr and weighed\70 kg, in which case they received oral iron and folate supplementation. Results The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group. Conclusion A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT. RésuméObjectif Nous avons voulu e´valuer l'effet d'un protocole pre´ope´ratoire re´partissant les patients devant subir une arthroplastie totale afin qu'ils suivent l'une de quatre strate´gies dans le but de diminuer le risque de transfusion de sang alloge`ne (TSA) selon leur risque a priori de transfusion sur l'exposition pe´riope´ratoire a`du sang alloge`ne. Méthode Nous avons compare´les expe´riences de transfusion d'une se´rie historique de cas te´moins compose´e de 160 patients a`un groupe d'e´tude de 160 patients traite´s sur la base de notre protocole. Les patients de notre protocole pre´sentant un taux d'he´moglobine (Hb) de 100-129 gÁL -1 ont reçu de l'e´rythropoı¨e´tine, dose´e en fonction de leur poids. Les patients ayant une Hb de 130-139 gÁL -1 ont subi une re´colte pre´ope´ratoire et une re-perfusion pe´riope´ratoire de sang autologue lorsque cela a éte´juge´ne´cessaire d'un point de vue clinique. Les patients ayant une Hb [139 gÁL -1 n'ont pas fait l'objet d'une intervention spe´ciale, sauf s'ils e´taient aˆge´s de[ 70 ans et pesaient \ 70 kg; dans ce cas, ils ont reçu des supple´ments de fer et d'acide folique par voie orale. Résultats Le risque relatif de TSA dans le groupe a`l'e´tude e´tait de 0,68 (intervalle de confiance 95 %, 0,54-0,85). Le groupe te´moin a reçu 104 unite´s de sang alloge`ne, contre 35 dans le groupe a`l'e´tude (P = 0,0007). Ces diffe´rences ne peuvent s'expliquer par des diffe´rences au niveau du risque

What Should Define Preoperative Anemia in Primary THA?

“…This has important implications preoperatively since compared with sex and the inability to receive TXA, this is a modifiable variable. The identification and treatment of preoperative anemia before lower extremity arthroplasty with specialist referral, iron supplementation, and erythropoietin-stimulating agents have been shown to reduce transfusions, LOS, 90-day readmissions, and costs [9,15,17,20,22,24,36], yet there are no guidelines or cutoffs to suggest which patients would benefit from these treatment programs or to identify preoperative Hgb targets to ensure one is ''ready'' for THA. We recommend that in addition for screening with BMI and hemoglobin A1c for obesity and diabetes, respectively, patients have preoperative hemoglobin checked 4 weeks before THA [15].…”

Effectiveness of Fibrin Sealant after Cementless Total HIP Replacement: A Double-Blind Randomized Controlled Trial

“…When standard procedures are used, perioperative blood loss in primary total hip replacement (THR) can exceed 1 liter (1)(2)(3). This hematic loss results in a high rate ofblood transfusion after THR (4)(5)(6). Blood transfusion can be used as a systemic method to solve blood loss but has the disadvantages of shortage of supply (7), high costs (8) and health risks (9,10) of allogeneic blood units.…”

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

“… 15 The most frequently used definition of anemia is the World Health Organization (WHO) 19 classification using a hemoglobin <13 g/dL (men) and <12 g/dL (women). Two SRs, 14 , 20 1 RCT, 21 and several observational studies 22 – 26 have shown iron (oral and intravenous) supplementation, erythropoietin, and preoperative autologous donation are effective in reducing postoperative allogenic transfusion; however, the benefit on clinical outcomes (ie, LOS and mortality) is unclear. Routine use of these strategies does not appear to benefit nonanemic patients.…”