Clinical efficacy of postoperative autologous transfusion of filtered shed blood in hip and knee arthroplasty. Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Prospective comparative study of two different autotransfusion methods versus control group in total knee replacement Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement. An analysis of blood management in patients having a total hip or knee arthroplasty. Allogeneic blood transfusion decreases with postoperative autotransfusion in hip and knee arthroplasty. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Impact of postoperative shed blood transfusion, with or without leucocyte reduction, on acute‐phase response to surgery for total knee replacement A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty. Does Single Use of an Autologous Transfusion System in TKA Reduce the Need for Allogenic Blood?: A Prospective Randomized Trial Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty. The utility of the perioperative autologous transfusion system OrthoPAT® in total hip replacement surgery: a prospective study Preoperative use of recombinant human erythropoietin before total joint arthroplasty. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: A study protocol Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. The association of preoperative anemia and perioperative allogeneic blood transfusion with the risk of surgical site infection. Investigation of the Use of Drained Blood Reinfusion after Total Knee Arthroplasty: A Prospective Randomised Controlled Study Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients. Patients with pertrochanteric hip fracture may benefit from preoperative intravenous iron therapy: a pilot study. Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial. Benefits of postoperative shed blood reinfusion in patients undergoing unilateral total knee replacement The timing of tourniquet release and 'retransfusion' drains in total knee arthroplasty: A stratified randomised pilot investigation. Incidence and risk factors for allogenic blood transfusion during major joint replacement using an integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia. A randomized trial on the efficacy of an autologous blood drainage and transfusion device in patients undergoing elective knee arthroplasty.
BACKGROUND Total knee arthroplasty ( TKA ) or total hip arthroplasty ( THA ) regularly results in postoperative requirement of blood transfusion . Because of the disadvantages of allogeneic blood transfusion ( ABT ) such as the risk of transfusion-associated infections , incompatibility-related transfusion fatalities , or immunomodulatory effects , a continuing effort to reduce allogeneic blood transfusion is important . For this purpose , the effect of reinfusion of drain blood , via a postoperative wound drainage and reinfusion system , on the need for allogeneic blood transfusion was evaluated . STUDY DESIGN AND METHODS Using a prospect i ve observational quality assessment design , we compared 135 patients scheduled for TKA or THA with a historic group of 96 patients . In the study group the Bellovac ABT autotransfusion system was used . The shed blood was returned either when 500 mL were collected or at most 6 hours after surgery . Compared were the preoperative , postoperative , and discharge hemoglobin , as well as the number of allogeneic blood transfusions . RESULTS There were no statistical differences between preoperative , postoperative , and discharge hemoglobin levels . Autologous transfusion reduced the number of patients receiving ABT overall from 35 percent ( control ) to 22 percent ( study ) . The decrease of allogeneic transfusion requirement was most significant after TKA : from 18 percent to 6 percent ( p < 0.001 ) . CONCLUSION We conclude that the Bellovac ABT device reduces allogeneic blood transfusions in TKA and THA BACKGROUND There are few data on the associations between anaemia , allogeneic blood transfusion ( ABT ) , patient blood management , and outcome after arthroplasty in the UK . National agencies nevertheless instruct NHS Trusts to implement blood conservation measures including preoperative anaemia management . Internationally , blood management programmes show encouraging results . METHODS We retrospectively audited 717 primary hip or knee arthroplasties in a UK general hospital and conducted regression analyses to identify outcome predictors . We used these data to modify previously published algorithms for UK practice and audited its introduction prospect ively . The retrospective audit group served as a control . RESULTS Preoperative haemoglobin ( Hb ) concentration predicted ABT ( odds ratio 0.25 per 1 g dl(-1 ) , P<0.001 ) . It also predicted the length of stay ( LOS , effect size -0.7 days per 1 g dl(-1 ) , P=0.004 ) independently of ABT , including in non-anaemic patients . Patient blood management implementation was associated with lower ABT rates for hip ( 23 - 7 % , P<0.001 ) and knee ( 7 - 0 % , P=0.001 ) arthroplasty . LOS for total hip replacement and total knee replacement decreased from 6 ( 5 - 8 ) days to 5 ( 3 - 7 ) and 4 ( 3 - 6 ) days , respectively , after algorithm implementation ( P<0.001 ) . The all-cause re-admission rate within 90 days decreased from 13.5 % ( 97/717 ) before to 8.2 % ( 23/281 ) after algorithm implementation ( P=0.02 ) . CONCLUSIONS We conclude that preoperative Hb predicts markers of arthroplasty outcome in UK practice . A systematic approach to optimize Hb mass before arthroplasty and limit Hb loss perioperatively was associated with improved outcome up to 90 days after discharge Aim The aim of this study was to evaluate the efficacy of two different autotransfusion methods in total knee replacement ( TKR ) performed without tourniquet , in comparison to allogeneic blood transfusion ( ABT ) only . Method In a comparative study , 248 patients with knee osteoarthritis were r and omized in three groups : in control Group 85 the patients underwent only ABT post-operatively , in Group 1 ( n:92 ) an intraoperative and postoperative autotransfusion were utilized , and in Group 2 ( n:71 ) only a postoperative autotransfusion was applied . Post-operative ABT was utilized according to predetermined criteria . Results Comparing Group 0 to Group 1 and 2 the difference in need for ABT post-operatively was statistically highly significant ( p < 0.001 ) even when the results were analyzed classifying the patients according to the preoperative Hb levels . The difference between Group 1 and 2 was not significant . Conclusion According to the results of this study , auto-transfusion reduces the need for ABT  in TKR performed without tourniquet Background : Total knee arthroplasty ( TKA ) is often associated with a considerable amount of post‐operative blood loss , necessitating the transfusion of allogeneic blood , which can add to the complications . Optimization of strategies to reduce the need for blood transfusion is desired . This study was design ed to evaluate the efficacy of autologous platelet gel and fibrin sealant  in unilateral TKA BACKGROUND Unilateral total knee replacement ( TKR ) can result in a substantial blood loss and 30 - 50 % of these patients receive allogeneic blood transfusion ( ABT ) , this transfusion rate may be even higher among anaemic patients . PATIENTS AND METHODS We assessed the requirements for ABT  in 156 consecutive patients undergoing surgery for primary TKR , who received iron ferrous sulphate ( 256 mg/day ; 80 mg of Fe(2 + ) ) , vitamin C ( 1000 mg/day ) and folic acid ( 5mg/day ) during the 30 - 45 days preceding surgery , and who were transfused if Hb < 80 g/L and /or clinical signs/symptoms of acute anaemia/hypoxemia ( Group 2 ) . A previous series of 156 TKR patients serves as a control group ( Group 1 ) . RESULTS Compared to those in Group 1 , patients in Group 2 presented a lower transfusion rate ( 5.8 % vs. 32 % , for Group 2 and Group 1 , respectively ; p<0.01 ) , and a lower transfusion index ( 1.78+/-0.44 vs. 2.22+/-0.65 units per transfused patient , respectively ; p<0.05 ) . After patient 's stratification according to a preoperative Hb above or below 130 g/L , the differences in transfusion rate remained significant , although 19 % of patients from Group 2 still needed ABT if their preoperative Hb < 130 g/L. CONCLUSION This protocol seems to be effective for avoiding ABT in non-anaemic TKR patients , whereas for anaemic patients another blood saving strategy , such us preoperative erythropoietin administration or postoperative blood salvage , should be added to further increase its effectiveness Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty . A total of 9482 patients ( 3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement ) were evaluated prospect ively from September 1996 through June 1997 . Of those patients , 4409 ( 46 percent [ 57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement ] ) had a blood transfusion . Two thous and eight hundred and ninety patients ( 66 percent ) received autologous blood , and 1519 patients ( 34 percent ) received allogenic blood . Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood . Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood ; however , inefficiencies in the procedures for obtaining autologous blood were identified . Sixty-one percent ( 5741 ) of the patients had predonated blood for autologous transfusion , but 4464 ( 45 percent ) of the 9920 units of the predonated autologous blood were not used . Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units . Of the 5741 patients who had predonated blood , 503 ( 9 percent ) needed a  transfusion of allogenic blood .  The frequency of allogenic blood transfusion  varied with respect to the type of operative procedure ( revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions ) and with a baseline hemoglobin level of 130 grams per liter or less . Transfusion of allogenic blood was also associated with infection ( p < or = 0.001 ) , fluid overload ( p < or = 0.001 ) , and increased duration of hospitalization ( p < or = 0.01 ) . These latter findings warrant further evaluation in controlled studies OBJECTIVES We aim ed to evaluate the effectiveness of postoperative autotransfusion method on prevention of the need of allogeneic blood transfusion  in hip and knee arthroplasty . METHODS Seventy-four patients who underwent 77 hip and knee arthroplasty operations were r and omized into control and study groups , and evaluated prospect ively . In the knee group ( 39 patients ; 30 females , 9 males ; mean age 66.6 years ) , cemented , cruciate retaining , and bicompartmental arthroplasty was performed under tourniquet control ; whereas in the hip group ( 35 patients ; 24 females , 11 males ; mean age 59.3 years )  cementless arthroplasty with posterolateral approach was performed . None of the patients received preoperative and intraoperative allogeneic blood transfusion . The collected blood in the surgical area was transfused with autotransfusion system to the patients in the study groups at the end of the fourth hour postoperatively . The mean amounts of autotransfused blood in hip and knee groups were 413 mL and 480 mL , respectively . Allogeneic blood transfusion was applied to the patients with hemoglobin level below 8 g/dL , hematocrit level below 25 % , and clinical symptoms of anemia . RESULTS Preoperative and postoperative hemoglobin-hematocrit levels did not differ significantly between study and control groups .  Allogeneic blood transfusion  was applied to one patient ( 5 % ) in study and 8 patients ( 38 % ) in control groups during knee arthroplasty ( p=0.01 ) ; whereas 9 patients ( 53 % ) in study and 15 patients ( 79 % ) in control groups received  allogeneic blood transfusion  during hip arthroplasty ( p=0.044 ) . The amount of allogeneic blood transfusion in study groups was significantly lower than that in control groups ( p=0.008 for knee arthroplasty , p=0.048 for hip arthroplasty ) . CONCLUSION The need and amount of allogeneic transfusion were reduced with postoperative autotransfusion in both knee and hip arthroplasty groups with greater extent in knee arthroplasty BACKGROUND The purpose of this study was to assess current practice s in blood management in elective orthopedic surgery in Europe . STUDY DESIGN AND METHODS For this 225-center prospect i ve survey , data were collected on 3996 patients .  Actual perioperative blood loss was compared to preoperative estimates . Differences in Hb levels and other outcome variables for patients receiving allogeneic versus autologous transfusions  were evaluated . The probability of allogeneic transfusion  based on selected predictor variables was estimated . RESULTS A total of 2640 ( 67 % ) hip and 1305 ( 33 % ) knee arthroplasty patients were evaluated .  Estimated blood loss ( median , 750 mL ) was significantly lower than computed blood loss ( median , 1944 mL ) . A total of 2762 ( 69 % ) patients received  transfusions  , including 1393 ( 35 % ) autologous-only and 1024 ( 25 % ) allogeneic-only . The probability of allogeneic transfusion  decreased with increasing baseline Hb , but differentially so for men and women . Transfusion triggers were Hb levels of 8.93 + /- 1.83 g per dL for allogeneic transfusions , and 21 percent of these occurred when the Hb level was greater than 10 g per dL. Autologous blood transfusion was associated with a significantly lower rate ( 1 % ) of wound infections than allogeneic blood transfusion ( 4.2 % ) . CONCLUSION Accurate assessment of preoperative Hb levels , better estimation of perioperative blood loss , efficient use of autologous blood , adherence to transfusion guidelines , and pharmacologic alternatives contribute to effective and comprehensive blood and anemia management Background : In patients undergoing total knee replacement ( TKR ) most blood loss occurs postoperatively and return of unwashed filtered shed blood ( USB ) from postoperative drainage may represent an alternative to allogeneic blood transfusion ( ABT ) . We evaluated the impact of USB return , with or without leucocytes , on the acute‐phase response ( APR ) after TKR We undertook a prospect i ve , r and omised study in order to evaluate the efficacy of clamping the drains after intra-articular injection of saline with 1:500 000 adrenaline compared with post-operative blood salvage in reducing blood loss in 212 total knee arthroplasties . The mean post-operative drained blood volume after drain clamping was 352.1 ml compared to 662.3 ml after blood salvage ( p < 0.0001 ) . Allogenic blood transfusion was needed in one patient in the drain group and for three in the blood salvage group . Drain clamping with intra-articular injection of saline with adrenaline is more effective than post-operative autologous blood transfusion in reducing blood loss during total knee arthroplasty Background Mechanical autotransfusion systems for washed shed blood ( WSB ) were introduced to reduce the need for postoperative allogenic blood transfusions ( ABTs ) . Although some authors have postulated decreased requirements for ABT by using autologous retransfusion devices , other trials , mostly evaluating retransfusion devices for unwashed shed blood ( USB ) , verified a small or no benefit in reducing the need for postoperative ABT . Because of these contradictory findings it is still unclear whether autologous retransfusion systems for WSB can reduce transfusion requirements . Questions / purpose sWe therefore asked whether one such autologous transfusion system for WSB can reduce the requirements for postoperative ABT . Methods In a prospect i ve , r and omized , controlled study , we enrolled 151 patients undergoing TKA . In Group A ( n = 76 patients ) , the autotransfusion system was used for a total of 6 hours ( intraoperatively and postoperatively ) and the WSB was retransfused after processing . In Control Group B ( n = 75 patients ) , a regular drain without suction was used . We used signs of anemia and /or a hemoglobin value less than 8 g/dL as indications for transfusion . If necessary , we administered one or two units of allogenic blood . Results Twenty-three patients ( 33 % ) in Group A , who received an average of 283 mL ( range , 160–406 mL ) of salvaged blood , needed a mean of 2.1 units of allogenic blood , compared with 23 patients ( 33 % ) in Control Group B who needed a mean of 2.1 units of allogenic blood . Conclusions We found the use of an autotransfusion system did not reduce the rate of postoperative ABTs . Level of Evidence Level II , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence Introduction An important percentage of patients affected by hip fracture require the administration of allogenic blood transfusion ( ABT ) to avoid the risks of perioperative acute anaemia . However , concerns about ABT risks have led to the search for alternatives , especially in elective orthopaedic surgery . Material s and methods We have prospect ively investigated the effect of preoperative intravenous 200–300 mg ( group 2 ; n=20 ) iron sucrose on ABT requirements and postoperative morbid-mortality in patients undergoing surgery for displaced subcapital hip fracture ( DSHF ) repair . A previous series of 57 DSHF patients served as the control group ( group 1 ) . All patients were older than 65 years , were operated on the 3rd day after admission to the hospital , by the same medical team , and using the same implant . Age , gender , ASA classification , surgical procedure , perioperative haemoglobin , requirements for ABT , postoperative infection , length of hospital stay ( LOS ) and 30-day mortality rate were examined . Results No adverse reactions to the iron administration were observed . The iron group had a lower transfusion rate ( 15 % vs 36.8 % ) , lower transfusion index ( 0.26 vs 0.77 units per patient ) , lower 30d mortality rate ( 0 vs 19.3 % ) , shorter LOS ( 11.9 vs 14.1 days ) , as well as a trend to a lower postoperative infection rate ( 15 % vs 33 % ) . Conclusion Preoperative parenteral iron administration could be a safe and effective way to reduce the ABT requirements in DSHF patients . This reduction in the ABT requirements is accompanied by a reduction in the morbid-mortality rate and LOS . A large , r and omised , controlled trial to confirm these results is warranted We have prospect ively evaluated the efficacy of an individualized pre-operative blood saving protocol in elective total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) . The primary aim was to obtain a pre-operative haemoglobin ( Hb ) level of > or = 14 g dL(-1 ) . A reduction in requirements for allogeneic transfusion was considered the second aim . Several strategies are available for increasing pre-operative Hb levels and reducing red blood cell ( RBC ) transfusions following THA or TKA , but the success of these programmes depends on selecting the most appropriate treatment for each patient . Three hundred and five patients with an indication of elective THA or TKA were individually assigned to the following strategies according to Hb and ferritin levels and medical conditions : ( a ) no pre-operative intervention , ( b ) oral iron therapy , ( c ) intravenous ( i.v . ) iron therapy , ( d ) recombinant human erythropoietin alpha with i.v . iron and ( e ) pre-operative autologous donation ( PAD ) plus oral iron . Eighty-two percent of the patients reached a pre-operative Hb level of > or = 14 g dL(-1 ) compared with 62 % of patients with Hb levels of > or = 14 g dL(-1 ) at the baseline visit . Treatment with PAD showed a significant reduction in the pre-operative Hb levels . The rate of RBC transfusion was 18.8 % compared with 31.5 % of matched historic group ( P < 0.001 ) . In conclusion , all patients scheduled to undergo THA or TKA should be c and i date s for an individualized pre-operative blood salvage programme Background Total hip replacement ( THR ) is associated with a significant perioperative blood loss , and 30–50 % of these patients receive allogeneic blood transfusion ( ABT ) . We evaluated the clinical utility of washed shed blood ( WSB ) return to reduce ABT in THR patients . Study design and methods Data from 108 consecutive THR patients were prospect ively collected .  WSB salvage and reinfusion ( OrthoPAT ) was intended for 60 ( Reinfusion group ) , whereas the remaining 48 patients served as control group . Patients received ABT if haemoglobin < 8 g/dl or clinical signs and symptoms of acute anemia . Results WSB return was possible in 49 patients ( 205 ± 151 ml of erythrocyte/patient ) , without any clinical ly relevant incident . Return of WSB decreased both the ABT rate ( 48 vs. 15 % , for control and reinfusion groups , respectively ; P = 0.001 ) and the ABT index ( 371 ± 154 ml RBC vs. 53 ± 117 ml RBC , respectively ; P = 0.001 ) , without differences between cemented and uncemented THR . In addition , patients from reinfusion group showed a trend to lower postoperative infection rate ( 10 vs. 2 % , respectively ; P = 0.086 ) . Conclusions Perioperative salvage and return of WSB in THR seems to effectively reduce the requirements for ABT . However , for patients with preoperative Hb < 13 g/dl , some additional blood saving method should be associated to WSB return BACKGROUND Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion . The purpose of this study was to evaluate the efficacy of erythropoietin in combination with , and compared with , preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty . METHODS Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens : ( 1 ) erythropoietin and preoperative autologous donation ( Group 1 ) , ( 2 ) erythropoietin alone ( Group 2 ) , and ( 3 ) preoperative autologous donation alone ( Group 3 ) . Patients were evaluated with regard to requirements for allogeneic transfusion , change from the baseline to the lowest postoperative hemoglobin value , postoperative complications , and adverse reactions . RESULTS The rate of allogeneic transfusion was 11 % in Group 1 ( erythropoietin and preoperative autologous donation ) compared with 28 % in Group 2 ( erythropoietin alone ) and 33 % in Group 3 ( preoperative autologous donation alone ) . Within Group 1 , patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4 % and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17 % . In Groups 2 and 3 , the allogeneic transfusion rates were 14 % and 15 % , respectively , for the patients who had a unilateral primary arthroplasty and 35 % and 47 % , respectively , for those who had a bilateral or revision arthroplasty . CONCLUSIONS Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone BACKGROUND Preoperative anemia has been associated with increased risk of allogeneic blood transfusion and postoperative morbidity and mortality . The prevalence of preoperative anemia and its association with postoperative outcomes has not previously been reported in relation to fast-track  elective total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) . We aim ed to evaluate the prevalence of preoperative anemia in elective fast-track THA and TKA and its association with risk of perioperative transfusion , prolonged length of hospital stay ( LOS ) , and postoperative readmission . STUDY DESIGN AND METHODS This was a prospect i ve observational data base study with data obtained from six high-volume Danish fast-track surgical centers . Preoperative hemoglobin and patient demographics were collected prospect ively using question naires while outcome and transfusion data were collected using national data bases and patient charts . Adjusted risk estimates for transfusion , prolonged LOS , and all-cause readmission according to preoperative anemia status were obtained by multivariate logistic regression . RESULTS A total of 5.165 THA or TKA procedures were included with a mean patient age of 67 ± 11 years and a median LOS of 2 ( interquartile range , 2 - 3 ) days . A total of 662 patients ( 12.8 % ) had preoperative anemia  according to World Health Organization classification . Preoperative anemia was associated with increased risk of receiving transfusion during admission ( odds ratio [ OR ] , 4.7 ; 95 % confidence interval [ CI ] , 3.8 - 5.8 ) , increased risk of readmission within 90 days from surgery ( OR , 1.4 ; 95 % CI , 1.1 - 1.9 ) , and increased risk of LOS of more than 5 days ( OR , 2.5 ; 95 % CI , 1.9 - 3.4 ) after adjustment for preoperative patient-related risk factors . CONCLUSION Preoperative anemia in elective fast-track THA and TKA is independently associated with transfusion and increased postoperative morbidity , supporting the need for preoperative evaluation and treatment Background Total hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery . Different blood-saving measures ( BSMs ) are used to reduce the often-needed allogenic blood transfusions in these procedures . A recent large r and omized controlled trial showed it is not cost effective to use the BSMs of erythropoietin and perioperative autologous blood salvage in elective primary hip and knee arthroplasties . Despite dissemination of these study results , medical professionals keep using these BSMs . To actually change practice , an implementation strategy is needed that is based on a good underst and ing of target groups and setting s and the psychological constructs that predict behavior of medical professionals . However , detailed insight into these issuses is lacking . Therefore , this study aims to explore which groups of professionals should be targeted at which setting s , as well as relevant barriers and facilitators that should be taken into acount in the strategy to implement evidence -based , cost-effective blood transfusion management and to de-implement BSMs . Methods The study consists of three phases . First , a question naire survey among all Dutch orthopedic hospital departments and independent treatment centers ( n = 99 ) will be conducted to analyze current blood management practice . Second , semistructured interviews will be held among 10 orthopedic surgeons and 10 anesthesiologists to identify barriers and facilitators that are relevant for the uptake of cost-effective blood transfusion management . Interview questions will be based on the Theoretical Domains Interview framework . The interviews will be followed by a question naire survey among 800 medical professionals in orthopedics and anesthesiology ( 400 professionals per discipline ) in which the identified barriers and facilitators will be ranked by frequency and importance . Finally , an implementation strategy will be developed based on the results from the previous phases , using principles of intervention mapping and an expert panel . Discussion The developed strategy for cost-effective blood transfusion management by de-implementing BSMs is likely to reduce costs for elective hip and knee arthroplasties . In addition , this study will lead to generalized knowledge regarding relevant factors for the de-implementation of non-cost-effective interventions and insight in the differences between implementation and de-implementation strategies BACKGROUND Unilateral total knee replacement ( TKR ) results in a substantial blood loss and 30 to 50 percent of patients receive allogeneic blood transfusion ( ABT ) . Therefore , the effectiveness of a restrictive transfusion trigger ( hemoglobin [ Hb ] level < 8 g/dL ) plus stimulation of erythropoiesis was evaluated , with or without blood salvage , for reducing ABT in TKR patients . STUDY DESIGN AND METHODS A series of 139 consecutive of primary TKR patients received perioperative iron sucrose ( 2 x 200 mg/48 hr , intravenously [ IV ] ) , plus preoperative erythropoietin ( EPO ; 1 x 40.000 UI , sc ) if preoperative Hb level was less than 130 g per L ( Group A ) . This protocol was applied to another series of 173 consecutive TKR patients who also received postoperative unwashed shed blood ( USB ) if preoperative Hb level was less than 130 g per L ( Group B ) . Perioperative clinical and laboratory data were gathered . RESULTS No adverse effects of iron sucrose , EPO , or USB administration were witnessed , and only 13 patients received ABT overall ( 4 % ) . No major differences in perioperative blood counts or iron metabolism variables were observed between groups , but stimulation of erythropoiesis seemed to be more pronounced in those patients receiving EPO ( p < 0.05 ) . There were no differences in postoperative complications between groups , but length of hospital stay for patients with a preoperative Hb level of less than 130 g per L was shorter in Group B ( p < 0.05 ) . CONCLUSION This blood saving protocol seems to be effective for reducing ABT in TKR patients . Which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment , however , needs to be further evaluated BACKGROUND The purpose of the study was to investigate allogeneic blood transfusion ( ABT ) and preoperative anemia as risk factors for surgical site infection ( SSI ) . STUDY DESIGN AND METHODS A prospect i ve , observational cohort of 5873 consecutive general surgical procedures at Basel University Hospital was analyzed to determine the relationship between perioperative ABT and preoperative anemia and the incidence of SSI .  ABT was defined as transfusion of leukoreduced red blood cells during surgery and anemia as hemoglobin concentration of less than 120 g/L before surgery . Surgical wounds and result ing infections were assessed to Centers for Disease Control st and ards . RESULTS The overall SSI rate was 4.8 % ( 284 of 5873 ) . In univariable logistic regression analyses , perioperative ABT ( crude odds ratio [ OR ] , 2.93 ; 95 % confidence interval [ CI ] , 2.1 to 4.0 ; p < 0.001 ) and preoperative anemia ( crude OR , 1.32 ; 95 % CI , 1.0 to 1.7 ; p = 0.037 ) were significantly associated with an increased odds of SSI . After adjusting for 13 characteristics of the patient and the procedure in multivariable analyses , associations were substantially reduced for  ABT  ( OR , 1.25 ; 95 % CI , 0.8 to 1.9 ; p = 0.310 ; OR , 1.07 ; 95 % CI , 0.6 to 2.0 ; p = 0.817 for 1 - 2 blood units and > or=3 blood units , respectively ) and anemia ( OR , 0.91 ; 95 % CI , 0.7 to 1.2 ; p = 0.530 ) . Duration of surgery was the main confounding variable . CONCLUSION Our findings point to important confounding factors and strengthen existing doubts on leukoreduced ABT during general surgery and preoperative anemia as risk factors for SSIs Purpose . To compare the use of a blood salvage and reinfusion system with st and ard allogeneic blood transfusion  after total knee arthroplasty — a procedure associated with significant postoperative blood loss . Methods . Between June 2002 and May 2004 , 60 patients undergoing total knee arthroplasty were r and omly allocated into a reinfusion group ( n=26 ) or a control group ( n=34 ) . Patients in the reinfusion group had their blood reinfused from drains within 6 hours of surgery . Both groups received allogeneic blood transfusions according to specified transfusion criteria if the haemoglobin level fell below 90 g/l , or in the presence of severe anaemic symptoms . Haemoglobin levels and drain output were recorded daily for 3 consecutive days after surgery . Results . There was no significant difference between the 2 groups in demographic data , drain output , total blood loss , and mean postoperative haemoglobin levels . Significantly more allogeneic blood was required by the control group than by the reinfusion group ( p=0.022 ) . Conclusion . Postoperative reinfusion of drained blood reduced the need for blood transfusion after total knee arthroplasty , while having an effect on postoperative haemoglobin level equivalent to st and ard allogeneic blood transfusion INTRODUCTION Extensive blood loss related to knee arthroplasty is quite normal and many patients require blood transfusions . Surgery and the use of pneumatic tourniquets lead to an increase in the activity of the fibrinolytic system , which in turn may accentuate the blood loss . Drugs that inhibit the fibrinolytic system may thus be used to reduce blood loss .  Tranexamic acid ( TA ) acts by binding to one of the enzymes at the start of the coagulation cascade , so inhibiting the fibrinolytic system . A concern is that this inhibition may have the side effect of increasing thromboembolic disease , a common complication of joint replacement surgery . We aim ed to confirm the reductions in blood loss and to assess the impact of TA usage on clinical and sub- clinical DVT . METHOD We performed a prospect i ve , r and omised , double blind , controlled trial , using patients due to undergo primary unilateral total knee arthroplasty . Patients were r and omised to receive either 15 mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing of the prosthesis .  Perioperative blood loss was recorded and patients were screened for DVT with duplex ultrasound assessment of both legs on the fifth post-operative day . RESULTS A statistically significant ( p=0.006 ) decrease in blood loss in the early post-operative period was noted in the group receiving tranexamic acid . This was not associated with a significant difference in total blood loss ( p=0.55 ) or in transfusion requirements . There was no of evidence in DVT in either group on duplex ultrasound screening of the lower limbs . INTERPRETATION One injection of 15 mg/kg of tranexamic given at the time of cementing the prosthesis in total knee arthroplasty , before deflation of the tourniquet , significantly decreases the amount of blood loss in the early post-operative period . The treatment was not associated with an increase in thromboembolic complications BACKGROUND Patients undergoing pertrochanteric hip fracture ( PHF ) repair surgery often receive perioperative allogeneic blood transfusions ( ABTs ) to avoid the deleterious effects of anemia . Nevertheless , concerns about adverse effects of ABTs have prompted the review of transfusion practice and the search for a safer treatment of perioperative anemia . MATERIAL AND METHODS The effect of preoperative 200 to 300 mg of intravenous ( IV ; Group 2 ; n = 55 ) iron sucrose administration on transfusion requirements and postoperative morbidity-mortality in patients with PHF has been prospect ively investigated . A previous series of 102 PHF patients served as the control group ( Group 1 ) . All patients were older than 65 years and were operated on at the third day after admission to the hospital , by the same medical team and with the same implant . RESULTS Iron sucrose was well tolerated and reduced the transfusion rate in patients with admission hemoglobin levels of greater than 120 g per L ( p < 0.05 ) who also received fewer units of red blood cells ( p < 0.05 ) . In addition , iron sucrose reduced postoperative infection rate ( p < 0.05 ) , but not 30-day mortality rate or mean length of hospital stay . CONCLUSION The administration of IV iron sucrose seems to reduce ABT requirements in patients with PHF and is associated to lower postoperative morbidity . The possible mechanisms involved in these effects are discussed Background Anemia is more often seen in older patients . As the mean age of hip fracture patients is rising , anemia is common in this population . Allogeneic blood transfusion ( ABT ) and anemia have been pointed out as possible risk factors for poorer outcome in hip fracture patients . Methods In the timeframe 2005 - 2010 , 1262 admissions for surgical treatment of a hip fracture in patients aged 65 years and older were recorded . Registration was prospect i ve from 2008 on . Anemic and non-anemic patients ( based on hemoglobin level at admission ) were compared regarding clinical characteristics , mortality , delirium incidence , LOS , discharge to a nursing home and the 90-day readmission rate . Receiving an ABT , age , gender , ASA classification , type of fracture and anesthesia were used as possible confounders in multivariable regression analysis . Results The prevalence of anemia and the rate of ABT both were 42.5 % . Anemic patients were more likely to be older and men and had more often a trochanteric fracture , a higher ASA score and received more often an ABT . In univariate analysis , the 3- and 12-month mortality rate , delirium incidence and discharge to a nursing home rate were significantly worse in preoperatively anemic patients .In multivariable regression analysis , anemia at admission was a significant risk factor for discharge to a nursing home and readmission < 90 days , but not for mortality . Indication for ABT , age and ASA classification were independent risk factors for mortality at all moments , only the mortality rate for the 3 - 12 month interval was not influenced by ABT . An indication for an  ABT  was the largest negative contributor to a longer LOS ( OR 2.26 , 95 % CI 1.73 - 2.94 ) and the second largest for delirium ( OR 1.67 , 95 % CI 1.28 - 2.20 ) . Conclusions This study has demonstrated that anemia at admission and postoperative anemia needing an ABT ( PANT ) were independent risk factors for worse outcome in hip fracture patients . In multivariable regression analysis , anemia as such had no effect on mortality , due to a rescue effect of PANT . In-hospital , 3- and 12-month mortality was negatively affected by PANT , with the main effect in the first 3 months postoperatively BACKGROUND Postoperatively shed blood salvage is commonly used to reduce allogenic blood transfusion in patients undergoing total hip ( THA ) and knee arthroplasty ( TKA ) . Autologous blood retransfusion is not devoid of risk . We hypothesized that adding tranexamic acid ( TXA ) to a restrictive blood transfusion protocol would reduce the need for postoperative autologous blood retransfusion in primary knee and hip arthroplasty . STUDY DESIGN AND METHODS Ninety-eight adult patients undergoing primary THA or TKA were r and omly assigned to receive an intraoperative intravenous loading dose of 1.0 g of TXA followed by another 1.0-g dose 3 hours later ( TXA group ) or a matching volume 0.9 % saline placebo ( control group ) . A postoperatively shed autologous blood recovery system was used in all patients and the minimum reinfusion volume set at 250 mL. Red blood cells were transfused if hemoglobin level was less than 8 or if 8 to 10 g/dL with symptoms of anemia . RESULTS The proportion of patients receiving autologous blood reinfusion was significantly lower in the TXA group ( 5/49 ) compared to placebo ( 42/49 ) with an absolute difference of -75.5 % ( adjusted relative risk , 0.005 ) , and none of the patients in the TXA group received more than 400 mL retransfused . Median total external blood loss during the first 24 hours was lower in the TXA group , 320 mL ( range , 80 - 930 mL ) , compared to 970 mL ( range , 100 - 2600 mL ) in the placebo group ( p < 0.001 ) . There were no significant differences in homologous blood transfusions and hematologic variables between groups . Treatment differences were consistent by size and significance when the analysis was repeated separately in patients undergoing TKA or THA . CONCLUSION Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary Introduction In patients undergoing total knee replacement ( TKR ) , most of the measured blood loss occurs during the postoperative period , and 30–50 % of these patients receive allogeneic blood transfusion ( ABT ) . For this reason , the salvage and return of unwashed filtered shed blood ( USB ) from postoperative drainage may represent an alternative to ABT in these patients . We have , therefore , evaluated the clinical utility of USB return in TKR patients , with a special focus on patients with mild anaemia . Material s and methods Data from 200 TKR patients ( group 2 ) receiving USB within the first 6 postoperative hours ( ConstaVac CBC II , Sryker ) were prospect ively collected . A retrospective series of 100 TRK patients served as the control group ( group 1 ) . Results USB return was possible in 162 patients who received a mean of 0.98±0.4 U/pte , without any clinical ly relevant incident . Return of USB decreased both the percentage of patients with ABT ( 48 % vs 11 % , for groups 1 and 2 , respectively ; p<0.01 ) and the ABT units/patient index ( 1.31±1.27 vs 0.29±0.87 units/patient , respectively ; p<0.01 ) . A transfusion protocol was not established , but there was no difference between groups with respect to either perioperative Hb levels or overall transfusion index , indicating that the transfusion criteria were uniform . However , for the subgroups of patients who needed ABT , the preoperative Hb level was 1 g/dL lower in those receiving USB ( 13.4±1.4 vs 12.4±1.2 g/dL ; p<0.05 ) . There was no difference in the postoperative complication rate , and patients in group 2 recovered the ability to walk 1 day earlier , and their hospital stay was 3 days shorter than in group 1 ( p<0.01 ) . Conclusions Return of USB after TKR seems to shorten the hospital stay and effectively reduce postoperative requirements for ABT , especially in patients with preoperative Hb > 13 g/dL. For patients with preoperative Hb < 13 g/dL , although the return of USB also decreased the requirements for ABT , a further reduction will probably be obtained with the addition of another blood-saving method The timing of tourniquet release is a potential confounding factor in the use of retransfusion drains in total knee arthroplasty . A pilot r and omised trial was performed using retransfusion drains to determine whether releasing the tourniquet after wound closure reduced the overall blood loss and allogenic transfusion rate .  Forty eight patients undergoing total knee arthroplasty were r and omly allocated to receive either a retransfusion drain or no drain . Within each group the tourniquet was released before or after wound closure at the discretion of the surgeon . The peri-operative fall in haemoglobin , allogenic blood transfusion rate and complication rate were measured . There was an overall transfusion rate of 16 % . There was no difference in the peri-operative fall in haemoglobin or the allogenic transfusion rates between the No Drain and Retransfusion Drain groups for patients undergoing total knee arthroplasty . Furthermore , the timing of the tourniquet release did not alter these findings . The results of this study suggest that the timing of the tourniquet release does not impact upon the ability of retransfusion drains to reduce the peri-operative fall in haemoglobin or the requirement for allogenic blood transfusion in total knee arthroplasty The efficacy of an integrated autotransfusion regimen , including pre-donation and perioperative salvage of autologous blood , was prospect ively evaluated in 2884 patients undergoing total hip ( n = 2016 ) or knee arthroplasty ( n = 480 ) , and hip revision ( n = 388 ) with either balanced general , regional , or integrated epidural/general anaesthesia .  Allogenic concentrated red blood cells were transfused in the presence of symptomatic anaemia or when haemoglobin concentration was < 6 g dL-1 ( 10 g dL-1 in patients affected by cerebrovascular or coronary artery disease ) after all salvaged and pre-donated autologous blood had been transfused . A total of 278 patients ( 9.6 % ) received allogenic blood . Risk factors for allogenic blood transfusion were : preoperative haemoglobin concentration < 10 g dL-1 ( after autologous blood pre-donations ) ( Odds ratio : 8.7 ; 95 % CI : 6.5 - 16.8 ; P = 0.004 ) , hip revision versus hip or knee arthroplasty ( Odds ratio : 5.8 ; 95 % CI : 3.9 - 8.5 ; P = 0 . 0001 ) and inability in obtaining the number of pre-donations required by the Maximum Surgery Blood Order on Schedule ( Odds ratio : 3.4 ; 95 % CI : 2.7 - 4.1 ; P = 0.0001 ) . The incidence of perioperative complications , including wound infection and haematoma , as well as myocardial ischaemia , respiratory failure and thromboembolic complications , was higher in those patients requiring allogenic blood transfusion ( 29.8 % ) than that observed in patients receiving only autologous blood ( 6.6 % ) ( P = 0.0005 ) ; while the mean time duration from surgical procedure to patient discharge from the orthopaedic ward was shorter in those patients not receiving allogenic blood transfusion ( 12 days ; 25 - 75th percentiles : 8 - 14 days ) than in those patients who required perioperative transfusion with allogenic blood ( 15 days ; 25 - 75th percentiles : 10 - 17 days ) ( P = 0.0005 ) . In conclusion , this prospect i ve study highlighted the clinical relevance of applying an extensive and integrated autotransfusion regimen in order to reduce allogenic blood transfusion and associated complications in patients undergoing major joint replacement The purpose of the study reported here was the determination of the efficacy of a postoperative autologous blood drainage and transfusion device in reducing allogeneic red cell requirements in patients undergoing elective knee arthroplasty . The study was a r and omized controlled trial with adult patients undergoing unilateral elective arthroplastic knee surgery . Patients underwent suction drainage , attached to an autologous blood drainage and transfusion device , or st and ard suction drainage . Allogeneic red cells were given according to strict transfusion guidelines based on blood loss and postoperative hemoglobin values . Outcome measures included the mean number of allogeneic red cell concentrates required and the number of patients in each group who required no transfusion . Patients assigned to st and ard suction drainage had a mean allogeneic red cell utilization of 1.2 units ( SD 1.0 ) , as compared to a mean of 0.4 units ( SD 0.8 ) in the group undergoing drainage with the autologous blood drainage and transfusion device ( p = 0.0007 ) . The percentage of patients not requiring allogeneic red cells was significantly higher in the latter group ( 74.3 % vs. 32.5 % ; p = 0.002 ) . The postoperative drainage and transfusion device was efficacious in reducing the amount of allogeneic red cells required by patients undergoing knee arthroplasty , and its use result ed in a 42 percent reduction in the number of patients requiring allogeneic transfusion
Findings and Conclusion To our knowledge , this is the first meta- analysis to compare the clinical results between PAT and a control in joint replacement patients .
This meta- analysis has proven that the use of a PAT reinfusion system reduced significantly the dem and for ABT , the number of patients who require ABT and the cost of hospitalization after total knee and hip arthroplasty .
This study , together with other previously published data , suggests that PAT drains are beneficial .
Background Total hip or knee arthroplasty is an elective procedure that is usually accompanied by substantial blood loss , which may lead to acute anemia .
As a result , almost half of total joint arthroplasty patients receive allogeneic blood transfusions ( ABT ) .
Many studies have shown that post-operative auto-transfusion ( PAT ) significantly reduces the need for  ABT  , but other studies have question ed the efficacy of this method .