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Blood management in total hip replacement: an analysis of factors associated with allogenic blood transfusion Samuel Wong,* Howard Tang† and Richard de Steiger‡ *Western Hospital, Melbourne, Victoria, Australia †Epworth Health Care, The University of Melbourne, Melbourne, Victoria, Australia and ‡Northern Hospital, Melbourne, Victoria, Australia

Key words arthroplasty, blood loss, blood transfusion, clinical audit, hip, replacement, surgical. Correspondence Dr Samuel Wong, Western Hospital, Locked Bag 2, Gordon Street, Footscray, Vic. 3011, Australia. Email: [email protected] S. Wong MBBS; H. Tang MBBS; R. de Steiger MBBS, FRACS This paper was presented at the Australian Orthopaedic Association Annual Scientific Meeting, Melbourne, Australia in October 2014. Accepted for publication 27 January 2015. doi: 10.1111/ans.13048

Abstract Background: The aim of this study was to audit the blood transfusion practice throughout the Epworth Healthcare Hospitals for patients undergoing primary total hip replacement (THR). We determined if blood-saving techniques were having an impact on the risk of allogenic blood transfusion and which patients were at risk of receiving allogenic blood transfusion. Methods: This study uses a retrospective audit of 787 patients who had undergone primary THR surgery at three Melbourne hospitals: Epworth Richmond, Epworth Eastern and Epworth Freemasons in 2010. Patient demographics, transfusion requirements and blood-conserving techniques were recorded. Results: One hundred and eighty (23%) patients received allogenic blood transfusion and 18 (2.3%) patients received autologous blood transfusion. On multivariate analysis, preoperative anaemia (odds ratio (OR) 4.7, P < 0.0001), female gender (OR 3.1, P < 0.0001) and patient age (OR 1.07 per year of age increase, P < 0.0001) were shown to be significantly associated with higher risk of allogenic blood transfusion. Use of spinal anaesthetic was found to be associated with lower risk of transfusion (OR 0.6, P = 0.0180) compared with general anaesthetic alone. Cell saver, acute normovolaemic haemodilution and re-infusion drain tube usage did not have a significant impact on reducing the risk of allogenic blood transfusion. Conclusion: Identification of patients at risk of blood transfusion, correction of preoperative anaemia and a restrictive transfusion policy are important factors to consider in effective perioperative blood management.

Introduction There is an increasing demand for lower limb joint replacement. In 2013 there were 86 738 hip and knee replacement and revision procedures performed in Australia; this represents a 41% increase for hip and 70% increase for knee procedures since 2003.1 Joint replacement surgery is associated with significant amounts of blood loss and is a major area of blood product usage. Although there are benefits of blood transfusion such as improving tissue oxygenation, it is not without risk. Blood transfusion is associated with risks of blood-borne infection, transfusion reaction, alloimmunization, transfusion-related acute lung injury and mistransfusion.2 As such, safe perioperative blood management guidelines remain an © 2015 Royal Australasian College of Surgeons

important tool to improve patient outcomes and reduce the need for allogenic blood transfusion. A common strategy to reduce the need for allogenic transfusion is to employ blood-saving methods. Examples of these include patient autologous donation (PAD), cell saver, re-infusion drains and acute normovolaemic haemodilution (ANH). PAD involves collecting patient blood product prior to surgery and transfusing the blood back to the patient perioperatively if needed. Typically, 1 or 2 units (U) of blood are pre-donated. Cell saver involves collecting the blood shed during surgery, washing it and re-infusing the blood back intraoperatively. Re-infusion drain tubes collect blood from the surgical site post-operatively; this blood is re-infused if sufficient volume is collected within a limited time frame (usually 5 h post-operatively). ANZ J Surg 85 (2015) 461–465

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ANH involves removing some of the patient’s own blood immediately before surgery and replacing it with fluids, maintaining normal circulating volume. Red blood cell loss during surgery is thus reduced, and the patients receive their own blood back at the end of the operation. The decision to transfuse blood depends largely on individual patient factors as well as the clinical judgment of the treating clinician. In the recent publication ‘Patient Blood Management Guidelines: Module 2’ in 2012, the National Blood Authority has advocated a move towards a more restrictive transfusion policy. The guidelines recommend that patients should not be transfused based on a trigger haemoglobin level alone, but instead on global assessment of clinical status. They advise against transfusion if haemoglobin level is ≥100 g/L. Transfusion of a single unit of RBC, with reassessment of clinical efficacy, is suggested for post-operative patients without active bleeding, who have acute myocardial or cerebrovascular ischaemia and a haemoglobin level of 70–100 g/L.3 The general aim of this study was to examine current transfusion practice associated with THR surgery across the Epworth Healthcare group of hospitals in Melbourne, Australia. Specifically, our main objective was to find out which patients were at risk of receiving allogenic blood transfusion, and whether blood-saving techniques were having an impact on this risk. We also aimed to identify the documented reasons for transfusions. Finally, we sought to see how the indication for transfusion was related with patient haemoglobin level at time of transfusion.

Methods Data collection A retrospective audit was conducted for all patients who had undergone primary total hip replacement (THR) surgery at the Epworth Healthcare group of hospitals (Epworth Richmond, Epworth Eastern and Epworth Freemasons) between 1 January 2010 and 31 December 2010. Medical records of all patients coded for primary THR during the study period were obtained for analysis. Revision surgery and hemiarthroplasties were excluded from this audit. For each patient, we recorded a number of variables relevant for our study. Predictor variables included patient age, gender, American Society of Anesthesiologists (ASA) status, haemoglobin levels (preoperative, post-operative day 1 and at time of transfusion), method of anaesthesia during the hip replacement operation (spinal block or general anaesthesia alone), use of blood-saving measures (cell salvage, ANH, drain reinfusion) and transfusion-related variables (physical location where the transfusion was given, the clinician who ordered the transfusion and the indication for transfusion). Patients with preoperative or post-operative anaemia were also identified. Anaemia was defined as haemoglobin

Blood management in total hip replacement: an analysis of factors associated with allogenic blood transfusion.

The aim of this study was to audit the blood transfusion practice throughout the Epworth Healthcare Hospitals for patients undergoing primary total hi...
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