Download Transfuson therapy in orthopaedic surgical procedures

TRANSFUSION THERAPY IN ORTHOPAEDIC
SURGICAL PROCEDURESGrant Funds provided by
(A Continuing Education Self-Study Activity)
A Continuing Education Activity
Sponsored By
Certified for 1 AST, RN, or CBSPD credit
Grant Funds Provided By
GOING GREEN IN THE OR
Welcome to
TRANSFUSION THERAPY IN ORTHOPAEDIC
SURGICAL PROCEDURES
(A Continuing Education Self-Study Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is intended for use as a stand alone self-study activity. We suggest you take the
following steps for successful completion:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives.
2. Review the content of the self-study activity, paying particular attention to those areas that reflect the
objectives.
3. Complete the Test Questions and compare your responses with the answers provided.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. Pfiedler Enterprises will send certificate once the participant has completed all seven modules.
If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION:
2101 S. Blackhawk Street, Suite 220
Aurora, CO 80014-1475
Phone: 720-748-6144
Fax: 720-748-6196
Website: www.pfiedlerenterprises.com
© Pfiedler Enterprises - all rights reserved 2011
Transfusion Therapy in Orthopaedic Surgical Procedures
OVERVIEW
Blood loss during major orthopaedic procedures, such as total joint arthroplasty or complex spinal reconstructive
procedures, can be extensive; therefore, the need for allogeneic blood is a common requirement. However, allogeneic
blood transfusions are associated with well recognized risks and complications. In addition, blood and blood products
have become more expensive because of the specific preparation procedures now performed to minimize the risk of
transfusion-transmitted diseases. Providing safe blood for transfusion remains a challenge today, despite the advances
in the preparation of allogeneic blood. Technological advancements in perioperative blood salvaging techniques continue
to provide orthopaedic surgical patients with viable options to allogeneic blood transfusion as well as certain clinical
advantages. All members of the surgical team play a vital role in the proper application of blood salvaging techniques
in order to maximize their clinical benefits. This continuing education activity will provide a review of transfusion therapy
options for patients undergoing major orthopaedic surgical procedures. It will present a brief overview of the relevant
hematologic lab values, followed by a review of the indications for blood transfusion therapy. The clinical considerations
of allogeneic blood versus autologous blood and various methods for autologous blood transfusion in the surgical patient
will be discussed. The requirements and standards issued by regulatory bodies, accreditation agencies, and professional
associations related to blood transfusion therapy will be outlined. Finally, a review of the literature that cites pertinent
clinical studies of alternative blood transfusion methods in orthopaedic surgical patients will be presented.
OBJECTIVES
Upon completion of this continuing education activity, the participant should be able to:
1. Identify the clinical indications for blood transfusion therapy.
2. Compare the clinical considerations regarding the use of allogeneic versus autologous blood.
3. Differentiate the various methods of autologous blood transfusion available today.
4. Discuss the requirements of regulatory and accrediting agencies related to blood transfusion therapy.
5. Cite the results of current clinical studies on blood transfusion methods in orthopaedic surgical patients.
INTENDED AUDIENCE
This continuing education activity is intended for perioperative nurses, surgical technologists, and other health care
professionals who are interested in learning more about the clinical implications of blood loss in patients undergoing major
orthopaedic and complex spinal surgical procedures. Also, it will address the various methods for perioperative blood
transfusion therapy that is available today.
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for
2.0 contact hour(s).
Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participant’s
records for at least four (4) years as proof of attendance.
1
IACET Credit for Allied Health Professionals
Pfiedler Enterprises has been approved as an Authorized Provider by the International Association for Continuing Education
and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean, VA 22102.
CEU STATEMENT
As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that qualify under IACET guidelines.
Pfiedler Enterprises is authorized by IACET to offer 0.2 CEU (2.0 contact hours) for this program.
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation criteria. This material was
originally produced in September 2011 and can no longer be used after September 2013 without being updated; therefore,
this continuing education activity expires in September 2013.
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any
products.
SUPPORT
Grant funds for the development of this activity were provided by Stryker.
PLANNING COMMITTEE
Rose Moss, RN, MN, CNOR
Nurse Consultant
Moss Enterprises
Larkspur, CO
Judith Pfister, RN, BSN, MBA
Program Manager
Pfiedler Enterprises
Aurora, CO
EXPERT REVIEWERS
Chad Edmonson, CST
Certified Surgical Technologist
Sky Ridge Medical Center
Lone Tree, CO
Julia A. Kneedler, RN, MS, EdD
Director of Education
Pfiedler Enterprises
Aurora, CO
Donna Reeves, BA, MA, MEd, PhD
Consultant
Pfiedler Enterprises
Aurora, CO
2
DISCLOSURE INFORMATION
All planning committee members, expert reviewers, and authors participating in continuing education activities sponsored
by Pfiedler Enterprises are expected to disclose to the audience any real or apparent financial affiliations related to the
content of their activities. Detailed disclosure appears below. For live presentations disclosure will be made verbally.
Planning committee members, expert reviewers, authors and faculty information:
1. Have you (or your spouse/partner) had any personal financial relationship in the last 12 months with the manufacturer
of the products or services that will be presented in this continuing education activity (planner/reviewer) or in your
presentation (speaker/author)?
2. Type of affiliation/financial interest with name of corporate organization.
3. Will your presentation include discussion of any off-label or investigational drug or medical device?
Rose Moss, RN, MN, CNOR
1. No
2. None
3. No
Judith Pfister, RN, BSN, MBA
1.Yes
2. Co-owner of company that receives grant funds from commercial entities
3. No
Chad Edmonson, CST
1. No
2. None
3. No
Julia A. Kneedler, RN, MS, EdD
1.Yes
2. Co-owner of company that receives grant funds from commercial entities
3. No
Donna Reeves, BA, MA, MEd, PhD
1. No
2. None
3. No
3
PRIVACY AND CONFIDENTIALITY POLICY
Pfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding
continuing education. The information we collect is never shared with other organizations for commercial purposes. Our
privacy and confidentiality policy covers the site www.pfiedlerenterprises.com and is effective on March 27, 2008.
To directly access more information on our Privacy and Confidentiality Policy, type the following URL address into your
browser: http://www.pfiedlerenterprises.com/privacy-policy. In addition to this privacy statement, this website is compliant
with the guidelines for internet-based continuing education programs.
The privacy policy of this website is strictly enforced.
CONTACT INFORMATION
If site users have any questions or suggestions regarding our privacy policy, please contact us at:
Phone: 720-748-6144
Email:
[email protected]
Postal Address: 2101 S. Blackhawk Street, Suite 220
Aurora, Colorado 80014
Website URL:
http://www.pfiedlerenterprises.com
4
INTRODUCTION
Several major orthopedic surgical procedures, such as total joint arthroplasty and spinal fusion are associated with
significant blood loss; thus the need for allogeneic blood transfusions.1 Moreover, the visible, i.e., measured, blood
loss following total hip arthroplasty (THA) and total knee arthroplasty (TKA) may underestimate the true amount of total
blood loss, as some blood lost during these procedures is “hidden.” In a study of 101 THA and 101 TKA procedures
(with reinfusion of drained blood), the mean total blood loss following THA was 1510 mL and the hidden loss was
471 mL (26%); following TKA, the mean total blood loss was 1498 mL and the hidden loss was 765 mL (49%).2 This
study demonstrates that THA involves a small hidden loss, i.e., the total loss being 1.3 times that measured. However,
following TKA, there may be substantial hidden blood loss due to bleeding into the tissues and residual blood in the
joint. In most cases, the true total amount of blood loss can be determined by doubling the amount of that which is
measured.
Because of the significant blood loss associated with these procedures, the need for blood transfusion is high,
especially for patients undergoing joint arthroplasty procedures, as demonstrated in the following studies:
●●
●●
●●
●●
A prospective study comparing the incidence of minor and major complications in 50 patients undergoing bilateral
TKA with 50 patients undergoing bilateral THA demonstrated that despite preoperative autologous blood donation
and retransfusion, the need for allogeneic blood transfusion, despite preoperative autologous blood donation and
retransfusion, was high for both groups (34% for bilateral TKA and 20% for bilateral THA).3 In this study, patients,
gender, comorbidities, American Society of Anesthesiologists scores, and body mass indices were similar in both
groups; further, there was no difference in preoperative hemoglobin, operative time, anesthetic management,
postoperative surveillance, and hemoglobin at discharge.
Data collected from 154 cases of primary TKA patients demonstrated that between 18% to 52% of these patients
required transfusion.4
A retrospective study of 119 patients who underwent 124 shoulder arthroplasties (including primary uncomplicated
total shoulder arthroplasty, revision or complicated primary total shoulder arthroplasty, and hemiarthroplasty)
showed that a postoperative transfusion was received in 25% of these patients.5
A retrospective study of over 290,000 spinal surgery patients was conducted to assess both the utilization and the
cost of allogeneic blood transfusion in the US and Belgium.6 Red blood cell utilization occurred in approximately
7% of patients from both countries; however US patients received 6 units as compared to 3 units received
by Belgian patients. US patients used 64% more allogeneic blood and they also incurred greater costs per
hospitalization than Belgian patients.
The risks and complications associated with the routine use of allogeneic blood transfusion (i.e., infection, fluid, and
longer hospital stays) have led to the development of specific preparation procedures; as a result of the heightened
safety awareness by clinicians as well as regulatory and accrediting agencies combined with new preparation
procedures, blood and blood products have become more expensive.7 Therefore, in recent years, interest in various
alternatives to traditional allogeneic blood transfusion, including autologous transfusion therapy and intraoperative and
postoperative blood salvage, has grown.8
HEMATOLOGY LAB VALUES REVIEW
The ultimate decision to transfuse a patient is based on multiple clinical factors, such as cardiovascular status,
age, preoperative hemoglobin level, anticipated additional blood loss, cardiac output, and blood volume. The
guidelines discussed below will outline specific recommendations regarding when a transfusion is warranted. These
recommendations are based on hematologic laboratory values. Frist, in order to understand the rationale for these
indications, it is helpful to review normal hematologic lab values.
5
Red Blood Cells (Erythrocytes)
Red blood cell (RBC) values vary depending upon a number of factors including gender, age, and geographical location (see
Figure 1). RBCs are expressed as the number per microliter of blood (mcl). Normal value ranges are:9
●●
Men
4.7 to 6.1 million per mcl
●●
Women
4.2 to 5.4 million per mcl
Figure 1 – Red Blood Cells
Hemoglobin(Hgb)
Hemoglobin is the iron-containing pigment of RBCs that carries oxygen from the lungs to the tissues; it is the principal protein
in the red blood cell. The pigment in hemoglobin gives blood its red color. The amount of hemoglobin is expressed in grams per
100 milliliters of blood, written g/dL. Normal hemoglobin levels are:10
●●
Men
14-18 g/dL
●●
Women
11-16 g/dL
The hemoglobin values in elderly patients are slightly decreased.
Hematocrit (Hct)
Hematocrit is defined as the percentage of red blood cells in the whole blood; often, it is referred to as “crit.” Normal hematocrit
ranges for adults are:11
●●
Men39-54%
●●
Women34-47%
Significant clinical symptoms occur with a loss of greater than 30% of blood volume.12
2, 3-Diphosphoglycerate (2, 3-DPG)
Another important hematologic factor related to blood transfusion therapy is 2, 3-DPG. This organic phosphate is an isomer
(i.e., two or more substances that are composed of the same elements in the same proportions, but differ in properties due to
differences in the arrangement of atoms), that is manufactured in the red blood cells. It controls the movement of oxygen from
red blood cells to body tissues.13 2, 3-DPG is essential for oxygen release to the tissues because it alters and decreases the
affinity of hemoglobin for oxygen. It is important to note that stored blood loses its 2, 3 DPG level.
6
INDICATIONS FOR PERIOPERATIVE BLOOD TRANSFUSIONS
While the reasons for variation in transfusion practices in orthopedic surgery are not well understood, a recent review of
the literature identified two consistent, independent risk factors that influenced the use of RBC transfusion: decreased
hemoglobin level and increased patient age; other important risk factors included increased surgical complexity, low body
weight, the presence of additional comorbidities, and the female gender.14
In order to improve the perioperative management of blood transfusion and to reduce the risk of adverse events, various
factors must be taken into consideration; these are described below.
Red Blood Cell Transfusion Therapy
Maintaining adequate circulating blood volume is critical during surgery; this often is accomplished by the administration of
blood or blood components.15 Whole blood is rarely given, unless the patient has an acute, massive blood loss; more often,
packed RBCs are given to increase the oxygen-carrying capacity and to maintain the intravascular volume of the patient’s
blood. The purpose of an RBC transfusion is to augment oxygen delivery to tissues.16 Hemoglobin levels during active
bleeding do not provide a precise measure of tissue oxygenation, since adequate or inadequate fluid resuscitation can
significantly alter the measured hemoglobin concentration. Additionally, a number of factors must be considered besides the
blood hemoglobin level, including oxygenation in the lungs, blood flow, and tissue demands for oxygen. Because of these
factors, the assessment of the adequacy of oxygen delivery must be individualized for every patient, especially in patients
with limited cardiac reserve or with significant atherosclerotic vascular disease. If available, mixed venous O2 levels, O2
extraction ratios, or changes in oxygen consumption may be helpful in assessing tissue oxygenation. In addition to these,
other factors to consider include the anticipated degree and rate of blood loss, as well as the effect of body temperature or
medications and anesthetics on oxygen consumption.
As noted, RBCs are used for transfusions to augment oxygen delivery to the tissues. This is because the plasma in whole
blood adds volume without increasing the capacity to carry oxygen. Red blood cells consist of erythrocytes concentrated
from whole blood donations by centrifugation or collected by apheresis method.17 The component is anticoagulated with
citrate and may have had one or more preservative solutions added. Depending on which preservative-anticoagulant
system is used, the hematocrit of RBCs ranges from 50% to 65% to about 65% to 80%. A unit of RBCs contains:
●●
●●
●●
An average of 50 mL of donor plasma, ranging between 20 mL to 150 mL; this is in addition to the added preservative
and anticoagulant solutions.
Approximately 42.5 to 80 g of hemoglobin or 128-240 mL of pure red cells, depending on several factors, including
the hemoglobin level of the donor, the starting whole blood collection volume, the collection methodology, or further
processing.
Approximately 147- 278 mg of iron, mostly in the form of hemoglobin.
In addition, every unit of RBCs must retain at least 85% of the red cells in the original component. A transfusion of packed
red blood cells increases the patient’s hematocrit by 3%.
Preoperative Assessment
To improve the perioperative management of blood transfusion and adjuvant therapies and to reduce the risk of adverse
outcomes associated with transfusions, bleeding, or anemia, patient preparation is important. Prior to any elective surgical
procedure, a complete patient evaluation should be conducted. For orthopaedic procedures, this evaluation should
include:18
●●
A complete physical examination.
●●
A review of the patient’s medical history to identify risk factors that may influence the need for transfusion.
●●
A review of medications taken by the patient to determine if any will affect coagulation during and after the procedure.
7
●●
●●
A review of laboratory results.
Patient education about the risk of bleeding, need for transfusion, and the benefits and risks associated with the
transfusion method(s) selected.
Indications and Monitoring19
In consideration of the factors discussed above, the American Society of Anesthesiologists has outlined the following
recommendations for perioperative blood transfusions, primarily based on hemoglobin levels:
●●
Transfusion rarely is indicated when the hemoglobin level is above 10 g/dL.
●●
Almost always, transfusion indicated in patients when the hemoglobin level is below 6 g/dL.
●●
The determination of transfusion in patients whose hemoglobin level is between 6-10 g/dL should be based on any ongoing
indication of organ ischemia, the rate and magnitude of any potential or of actual bleeding, the patient’s intravascular
volume status, and the risk of complications due to inadequate oxygenation.
The use of alternative measures to reduce allogeneic red cell use should be considered, including preoperative autologous
donation, intraoperative and postoperative autologous blood recovery, acute normovolemic hemodilution, and the use of both
operative and pharmacologic measures that reduce blood loss.
Whenever a transfusion is given, the patient should be monitored closely for any signs of adverse events. Signs and symptoms
indicating a potential reaction or adverse event include:
●●
Urticaria
●●
Hypotension
●●
Tachycardia
●●
Increased peak airway pressure
●●
Hyperthermia
●●
Decreased urine output
●●
Hemoglobinuria
●●
Microvascular bleeding
BLOOD TRANSFUSION SOURCES
Blood for transfusion therapy either is homologous or autologous. Homologous or allogeneic blood is collected from another
person and banked; in contrast, autologous blood is self-donated (see Figure 2). There are advantages and disadvantages
associated with the transfusion of blood from each of these sources, as outlined below.
Figure 2 – Blood Donation Process
8
Homologous Blood
Historical Evolution of Blood Transfusion and Blood Safety20,21
The history of blood transfusions is long and varied. The first human blood transfusion was successfully performed in
the US by the American physician Philip Syng Physick in 1795, although he did not publish this milestone. In 1818, a
British obstetrician performed the first successful transfusion of human blood to a patient for the treatment of postpartum
hemorrhage. Blood donated from the arm of the patient’s husband was used. In 1907, it was recommended that the safety
of transfusions could be improved by cross matching blood between donors and patients to exclude incompatible mixtures.
The first blood bank was established in the United States in 1937 and the term “blood bank” was coined. Within a few
years, both hospital and community blood banks began to be established across the country.
Since that time, transfusions have been used to save patient lives and to improve clinical outcomes. It is estimated
that 10.8 million volunteers donate blood annually, 29% of which are first time donors; approximately 17 million units
of whole blood and red blood cells were donated in the United States in 2008. In addition, approximately 44,000 units
of blood are needed in hospitals and emergency treatment facilities every day in the US. In 2008, more than 23 million
blood components were transfused; and, with the aging population and advances in medical treatments and procedures
requiring blood transfusions, the demand for blood will continue to rise.
Initially, blood transfusion was considered to be relatively risk free. However, in 1943, the first description of transfusiontransmitted hepatitis through an infusion was published; despite this finding, testing the blood supply for Hepatitis B
surface antigen would not occur until 1973. In 1981, the first acquired immune deficiency syndrome (AIDS) case was
reported. In 1984, the human immunodeficiency virus (HIV) was identified as the cause of AIDS; this prompted the
licensing of the first blood-screening test to detect HIV in 1985, which was implemented by blood banks very quickly. The development of additional tests to protect the blood supply continued into the late 1990’s. In 1990, the first specific
test for the hepatitis C virus (HCV), the major cause of “non-A, non-B” hepatitis, was introduced. In 1992, testing of donor
blood for HIV antibodies was implemented. In 1997, the US Federal Government issued two reports suggesting ways
to improve the safety of blood, including regulatory reform. 1999 the implementation of Nucleic Acid Amplification Testing
(NAT) began; NAT employs a testing technology that directly detects the genetic materials of viruses like HCV and HIV.
In 2005, the US Food and Drug Administration’s (FDA) Center for Biologics Evaluation and Research publishes
compliance program guidance for inspection of human cells, tissues, and cellular and tissue-based products (HCT/Ps).
Also, in 2005, the FDA also approved the first West Nile virus (WNV) blood test to screen donors of blood, organs, cells
and tissues.
The discovery that WNV was transfusion-transmitted led to the realization that the only definitive way to avoid transfusiontransmitted disease is to avoid the use of donated blood products, unless the benefits of the transfusion outweigh the risks.
Disadvantages
In addition to HIV, HBV, HCV, and WNV, a number of other pathogens also can be transmitted through transfusion of
homologous blood; these include:22,23
●●
Human T-cell lymphotropic viruses (HTLV-I, -II). Relatively speaking, both of these viruses are uncommon in the US,
but they do occur more frequently in certain populations, e.g., HTLV-I is more common in Japan and the Caribbean.
This type of infection can persist for a lifetime, but it rarely causes major illnesses in most people who are infected.
In rare instances, after many years of infection, the virus may cause nervous system disease or an unusual type
of leukemia. Usually HTLV-II infections are associated with intravenous drug usage, especially among people who
share needles or syringes. While disease associations with HTLV-II have been hard to confirm, the virus may cause
subtle immunity abnormalities which can lead to frequent infections, or it may cause rare cases of neurological
disease.
9
●●
●●
●●
Cytomegalovirus (CMV). CMV, which is one of the herpes viruses which, unpredictably, may be present in white-cellcontaining components from donors who were previously infected with it. This can persist throughout the person’s life,
despite the presence of serum antibodies.
Syphilis. The risk of transmitting syphilis through a blood transfusion is exceedingly small (no cases have been
recognized in this country for many years) because the infection is very rare in blood donors and because the
spirochete is fragile and it is not likely to survive blood storage conditions.
Bacterial infection. Organisms which are capable of multiplying at low temperatures and those that use citrate as a
nutrient most often are associated with red cell contamination.
Of most concern are other known agents for which screening is unavailable and unknown agents that have yet to be
discovered.
Besides the transmission of infectious pathogens, other immediate transfusion risks and complications include:24
●● Transfusion-related acute lung injury (TRALI), which potentially is a life-threatening condition with symptoms that
include dyspnea, fever, and hypotension. TRALI occurs when the acutely increased permeability of the pulmonary
microcirculation causes massive leakage of fluids and protein into the alveolar spaces and interstitium; typically
this occurs within 6 hours of the transfusion. The specific mechanism of action is not clear. Treatment consists of
aggressive respiratory support.
●●
●●
Hemolytic transfusion reaction. This is the destruction of transfused red cells and it is usually due to blood type
incompatibility.
Immunomodulation, which may suppress the immune response and slightly increase the risk of postoperative
infection.
●●
Incorrect transfusion due to misidentifying patients.
●●
Allergic reactions, which usually occur as urticaria, but also may include wheezing or angioedematous reactions.
●●
●●
Anaphylactoid reactions, which are characterized by autonomic dysregulation, severe dyspnea, pulmonary and/
or laryngeal edema, and bronchospasm and/or laryngospasm. These types of reactions are rare, but serious
complications that require immediate treatment with corticosteroids and epinephrine.
Febrile nonhemolytic reaction is typically manifested by a temperature elevation of greater than or equal to 1° C
or 2° F, which occurs during or shortly after a transfusion and in the absence of any other pyrexic stimulus. Febrile
reactions may accompany about 1% of transfusions. Unfortunately, there are no routinely available pre- or posttransfusion tests that are helpful in predicting or preventing these reactions. Usually antipyretics provide effective
symptomatic relief.
An estimated total of 60,000 transfusion-related adverse reactions were reported for 2008; the adverse reaction rate (events
divided by the total components transfused) was 0.25%.25 In 2008, the total number of WB/ RBCs transfused in the US
equaled 15,014,000 units; the WB/RBC allogeneic transfusion rate was 48.8 units per thousand persons in the overall US
population; neither of these was a significant change from the 2006 data.
Because of safety concerns, blood centers banks have instituted criteria for screening for transmissible diseases. While
these efforts have increased the safety of the blood supply, they have also led to decreased availability of blood products in
some cases as well as increased costs.
A total of 62 hospitals (4.4%) surveyed by the American Association of Blood Banks (AABB) reported that elective surgery
was postponed on one or more days in 2008 due to a shortage of blood inventory.26 The number of reported days of delay
ranged from 1 to 100, with an average of 2 days; when the three outliers (100, 32, 40 days) were eliminated, the range of
the reported delay narrowed to 1 to 14 days.
10
Autologous Blood
While homologous blood is donated by strangers, autologous blood is donated by the patient. Exclusive or supplemental use
of autologous blood can eliminate or reduce many of the adverse effects of a blood transfusion. In addition, having a “known
donor” reduces many of the risks associated with allogeneic blood.
The use of blood donated by the patient has been shown to reduce the risk of allogeneic transfusion by 43.8%.27 In recent
years, due to the concerns associated with homologous blood, allogeneic transfusions have decreased and autologous blood
transfusions have increased significantly.28
AUTOLOGOUS BLOOD TRANSFUSION METHODS
There are three types of autologous blood transfusion methods available today:
●●
Preoperative autologous donation
●●
Intraoperative blood salvage
●●
Postoperative blood salvage
Each of these is described in detail below.
Preoperative Autologous Donation
As previously reviewed, with preoperative autologous blood transfusion, the patient predonates some of his or her own blood
which is then stored for possible reinfusion at a later date, i.e., when indicated during the surgical experience.29 For example,
a person might predonate one unit of blood every week for up to six weeks prior to surgery, because blood can be stored in its
liquid form for up to 42 days.30 Patients can make autologous donations up until 72 hours prior to their surgery. This is to allow
the body enough time to replenish its blood supply before the surgical procedure. The process of autologous blood donation
stimulates the bone marrow to produce new blood cells; with adequate time for recovery, the collected cells may be wholly
or partially replaced before the day of surgery. The decision regarding autologous donation and transfusion should be made
between the patient and surgeon jointly.
Preoperative autologous blood collection should be considered for patients scheduled for procedures in which the likelihood
of transfusion is high, such as major orthopedic procedures, the most common of which is total joint arthroplasty procedures.31
Autologous donation is appropriate for medically stable patients who are free from infection; other requirements for autologous
donation include:32
●● That the donor patient’s hemoglobin be no less than 11g/dL and the hematocrit of at least 33% before each donation.
●●
There are no age or weight limits.
●●
Patients may donate 10.5 ml per kg, in addition to the testing samples.
●●
Patients can donate blood beginning 6 weeks before the surgery. The donations can be scheduled every 72 hours, but
the last one should occur no less than 72 hours before surgery to allow time for restoration of the blood volume and the
transport and testing of the donated blood.
There are certain contraindications to autologous blood donation, including:33,34
●● Evidence of infection (this is an absolute contraindication).
●●
Unstable angina.
●●
Active seizure disorder.
●●
Myocardial infarction or cerebrovascular accident within 6 months of donation.
●●
Patients with significant cardiac or pulmonary disease who have not been cleared for surgery by their primary physician.
11
●●
Uncontrolled hypertension.
●●
History of blood disease.
Although autologous blood donation eliminates certain risks associated with homologous blood transfusions, some risks
remain while other risks arise. 35,36 The advantages of autologous donation include that it:
●●
Preventions transfusion-transmitted diseases and viral infections such as HIV, HBV, HCB.
●●
Preventions red-cell alloimmunization.
●●
Augments the blood supply.
●●
Prevents some adverse transfusion reactions.
●●
Provides compatible blood for patients with known blood compatibility problems due to alloantibodies.
●●
Provides reassurance to those patients who are concerned about blood transfusion risks.
The disadvantages of autologous blood donation include:
●● It does not affect the risk of bacterial contamination.
●●
●●
●●
●●
●●
It does not affect the risk of blood type (ABO) incompatibility error.
It subjects the patient to the development of perioperative anemia and an increased likelihood of transfusion,
resulting from preoperative donation.
The expenses associated with testing, processing, handling, and storing donated blood. Autologous donations
require separate storage as well as special handling, which can result in the process being more costly. For a major
orthopaedic procedure, anywhere between 1 to 6 units of blood can be processed.
Wasted predonated blood. As much as 44% of autologous donations are unused by the patient. If blood loss during
the procedure is less than anticipated, transfusion of the autologous blood may not be medically necessary. These
unused units generally are discarded because current standards do not allow transfusion of these units to another
patient due to safety reasons.
Potential delays in surgery time, if the processed blood is not available in time.
Intraoperative Blood Salvation
Intraoperative red blood cell salvation or collection, with the use of various cell processors, is another method of
autologous blood reinfusion. This method describes the technique of aspirating the blood shed into the surgical field
and into a specialized apparatus that concentrates the RBCs and washes the shed blood to remove debris; after which,
the RBCs are reinfused into the patient.37 Generally, it is used for procedures where anticipated blood loss is 20% or
greater and where there is no contamination of the area by bacteria or malignant cells.38 Generally, in orthopaedic
surgery, intraoperative cell salvage is indicated for major spine, bilateral knee replacement, and revision hip arthroplasty
procedures.39
There are many types of cell processors. Regardless of the manufacturer, essentially all of these processors are red blood
cell washing devices that collect anticoagulated shed blood, and that wash and separate the RBCs by centrifugation, and
then reinfuse the RBCs.40 Red blood cell washing devices can help remove byproducts and waste substances in salvaged
blood that may have been suctioned from the surgical field. However, they remove valuable platelets, clotting factors and
other plasma proteins critical to whole blood also. The various RBC-savers also yield RBC concentrates with different
characteristics and quality. If the shed blood is collected by sterile methods and properly reinfused, the procedure has few
risks.
12
There are certain contraindications for and potential adverse events associated with the use of intraoperative blood
salvage.41,42,43 Contraindications to intraoperative blood salvage include:
●● The use of certain pharmacologic agents. For example, when specific procoagulant materials, such as topical
collagen, are used in the surgical field, is systemic activation of coagulation may occur.
●●
●●
●●
●●
●●
●●
Blood containing iodophor and similar wound irritants used for irrigation or antibiotics that are not labeled for
parenteral use, as these should not be reinfused.
Methyl methacrylate. In the liquid form, methyl methacrylate may cause circulatory collapse if infused; in the
hardened state, the material may clog the autologous salvage system.
Infection. No existing system of blood filtering or washing can completely eliminate bacteria. As a result,
intraoperative blood salvage is not routinely used if the field is contaminated with bacteria, such as occurs in lower
gastrointestinal tract surgery.
Cancer. Malignant cells are not completely removed from salvaged blood by washing or filtration; therefore,
theoretically, there is a risk that transfusion of blood salvaged during surgery for malignancy may result in metastases.
The reinfusion of blood that is grossly contaminated with malignant cells should be avoided.
Contaminants. Contaminants in the blood, such as bone chips or fat are also contraindications for the use of cell
salvage.
Patients with hematologic disorders, e.g., thalassemia and sickle cell disease.
The contraindications to intraoperative cell salvage are summarized in Table 1.
Table 1 – Contraindications to Cell Salvage44
Pharmacologic Agents
Clotting agents (e.g., topical collagen products)
Irrigation solutions (e.g., povidone iodine, antibiotics intended for topical use)
Methyl methacrylate
Contaminants in the Blood
Urine
Bone chips
Fat
Bowel contents
Infection
Malignancy
Hematologic Disorders
Sickle cell anemia
Thalassemia
Miscellaneous
Carbon monoxide (associated with electrosurgery smoke)
13
Potential adverse events associated with intraoperative blood salvation include:
●● Embolus.
●●
●●
Hemolysis of recovered blood during suctioning.
Bacterial contamination. Positive bacterial cultures have been seen in recovered blood, however, clinical infection is
rare.
Postoperative Blood Salvage
With postoperative blood salvage, which is primarily used in orthopaedic and cardiac surgery patients, blood that is lost in
the early postoperative period is collected from a drainage tube at the surgical wound or joint drains and then transfused
to the patient, either washed or unwashed.45 Although diluted, the blood obtained contains viable and functional RBCs.46
Also, this method of transfusion also lacks many of the transfusion risks previously discussed. A postoperative blood salvage
system is depicted in Figure 3.
Figure 3 - Postoperative Blood Salvage System
Postoperative blood salvage and reinfusion have become popular in orthopedic procedures because of the increased risk for
blood loss, specifically:47
●● In total hip arthroplasty procedures, patients bleed both intraoperatively and postoperatively. Usually, 2 to 4 units of
predonated blood are ordered by the physician.
●●
●●
In total knee arthroplasty procedures, there is minimal intraoperative blood loss because of the tourniquet use;
however, there is a large volume of postoperative blood loss, and a higher risk of hematoma formation.
For spinal procedures, an enormous amount of predonated blood is ordered to be available, but much of it is never
used. During these procedures, there is a large potential for blood pooling on the spinal column and also a large
volume of blood loss on multi-level osteotomies.
Postoperative autologous blood salvage techniques and reinfusion systems offer certain distinct advantages over other
transfusion methods; these advantages include:48, 49,50
●● Potential time and cost savings. Postoperative blood salvage techniques and reinfusion systems are easy to use.
These systems reinfuse the postoperatively drained blood, which is normally discarded, thereby eliminating the need
for the patient to predonate his/her blood prior to surgery.
●●
14
Quality improvement, in terms of clinical outcomes. The patient’s blood level is maintained, thus reducing the need for
transfusion.
There are also certain risks associated with postoperative blood salvage, including:51,52
●● Dilutional coagulopathy. Because salvaged blood is deficient in coagulation factors and platelets, patients
receiving transfusions of large volumes of salvaged blood may develop certain coagulation disorders such as
hypofibrinogenemia, thrombocytopenia, and prolonged prothrombin (PT) and partial thromboplastin times (PTT).
●●
●●
Renal insufficiency. Infusion of large quantities of unwashed blood that contain hemolyzed RBCs may contribute to
renal failure, particularly in patients with already compromised renal function.
Embolism. As with all intravenous infusions, improper technique, such as applying pressure to air-containing systems,
may lead to air embolism.
Although some studies have questioned the safety of reinfusion of unwashed blood, most studies support the view that the
use of postoperative blood salvage methods can be implemented without any clinically relevant complications.
As with other autologous blood transfusion methods, there are certain contraindications to the use of a postoperative
reinfusion system; these contraindications include:53
●● Abnormal renal and/or hepatic function.
●●
Presence of malignant lesions.
●●
Presence of contamination or sepsis.
●●
Fluids that are unsuitable for reinfusion.
●●
Presence of amniotic fluid or bile.
●●
Excessive hemolysis.
●●
Coagulation disorders.
There are also potential complications associated with postoperative blood salvage, as outlined below.
●● The first potential complication is operator error. Difficult protocols regarding the proper use of postoperative salvage
systems may be tedious and therefore result in inadvertent operator error.
●●
●●
●●
Hemolyzed red blood cells are also a concern. Suction pressure over 100 mmHg, as well as excess handling, may
hemolyze red blood cells.
Another concern with postoperative reinfusion systems is the potential for bacterial infection. Although the blood
collection system is closed, if proper procedures are not followed, the potential for contamination still exists. Infection
is the most common reinfusion reaction.
The potential for air, micro-, or fat embolism also exists. The blood that is drained postoperatively from orthopedic
procedures contains fat from osteotomized cancellous bone; this fat must be addressed for patient safety.
General Considerations
Certain safety issues that must be taken into consideration when using any postoperative blood reinfusion system,
including: 54
●● The transfusion of shed blood collected under postoperative or posttraumatic conditions shall be completed within 6
hours of initiating collection.
●●
●●
Adherence to Standard and Transmission-Based Precautions must also be enforced in order to prevent an exposure
incident when handling any blood-related product.
Current federal and state regulations directing the handling and disposal of sharps must be followed.
15
●●
The collected blood should not be mixed with any medication. In addition, medication should not be “piggybacked”
into the flowing blood path. A sample protocol for the use of perioperative blood salvage and autologous transfusion techniques is outlined below;
general troubleshooting measures are listed in Table 2.
Sample Perioperative Blood Salvation Protocol
Perioperative blood salvage will be used whenever possible per physician order to minimize the need for and risks
associated with allogeneic blood transfusion.
The system will be used according to manufacturer’s recommendations and facility protocol. Staff members should
refer to all support information as needed, including the operator’s manual, in-service and other training materials,
and facility protocol.
All personnel will receive in-service training on specific blood salvage systems prior to use, including satisfactory
return demonstration on proper use.
Administration of all salvaged blood will be performed in compliance with facility protocol and standards of nursing
practice for blood administration.
The use of perioperative blood salvage systems will be documented according to facility documentation policies and
will include specified parameters, e.g., intake and output and all medications used in conjunction with the system,
as outlined in the policy.
Appropriate infection prevention practices will be followed at all times to reduce the risk for cross-contamination
according to facility infection control policies and the manufacturer’s recommendations for system cleaning and disinfection.
Intraoperative Procedures:
o Verify the use of blood salvage with the surgeon.
o Obtain all necessary supplies and equipment; ensure all equipment is available and in working order and
that there are no compromises in the sterility of packaged sterile items.
o Follow the manufacturer’s recommendations for system setup and operation.
o Use strict aseptic technique for sterile items on the sterile field.
o Provide the salvaged RBCs to the anesthesia provider for reinfusion to the patient within 6 hours of collection.
Postoperative Procedures:
o Verify the physician’s order for reinfusion of salvaged RBCs.
o Process the unit until empty, according to the manufacturer’s written instructions or facility protocol.
o Reinfuse the minimum amount of salvaged RBCs per facility policy, within 6 hours of collection.
o Discontinue the use of the system according to the physician’s order or facility protocol.
16
Table 2 – General Troubleshooting Measures for Blood Salvage/Autologous Transfusion55
Problem
Coagulation
Possible Cause(s)
Not enough anticoagulant
Action(s)
Add localized anticoagulant
as ordered or according to
manufacturer’s recommendations
Check for anticoagulation reversal
Coagulopathies
Decreased platelet and
fibrinogen levels
Platelets are caught in the
filter
Transfuse fresh frozen plasma or
platelet concentrate, as ordered,
for patients receiving autologous
transfusions of over 4,000 mL
Enhanced levels of fibrin split
products
Emboli
Microaggregate debris
Air
Avoid using equipment with
roller pumps or pressure infusion
systems; prior to reinfusion,
remove air from blood bags
Reinfuse with a microaggregate
filter according to manufacturer’s
instructions
Hemolysis
Trauma to blood caused by
roller pumps or turbulence
Avoid skimming the operative field
Avoid the use of equipment with
roller pumps
When aspirating blood from the
surgical site, keep the suction
vacuum pressure below 60 mmHg
or that recommended by the
manufacturer
Sepsis
Contaminated blood
Lack of sterile technique
Do not infuse blood from infected
areas or blood that is infected with
urine, feces, or other contaminants
Use strict aseptic technique;
administer broad-spectrum
antibiotics as ordered
17
REGULATIONS, STANDARDS, AND PRACTICE GUIDELINES RELATED TO BLOOD
TRANSFUSION THERAPY
It is apparent that blood transfusion therapy involves some inherent risks to the patient. Therefore, following regulations and
adhering to evidence-based best practices are critical in maintaining patient safety during any type of blood transfusion. The
applicable regulations, standards, and practice guidelines intended to promote the appropriate and safe use of blood and
blood products are briefly summarized below.
Federal Regulations
All blood collection facilities must comply with the standards and regulations specified in the Code of Federal Regulations,
Title 21, Food and Drugs, Part 606: Current Good Manufacturing Practice for Blood and Blood Components.56 The US FDA
oversees compliance with these standards.
American Association of Blood Banks (AABB) Standards
Also, the AABB sets forth standards for transfusion therapy in its Standards for Perioperative Autologous Blood Collection
and Administration.57 Unlike federal regulations, compliance with these standards is voluntary.
American Society of Anesthesiologists (ASA) Practice Guidelines58
The ASA’s Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies, as noted above, focus on the
perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss
occurs or is expected. These guidelines are applicable to procedures performed in operating rooms (ORs) in both inpatient
and outpatient surgical practice settings and also to procedures performed in other locations (e.g., interventional radiology
suites, critical care units) where blood transfusion or other adjuvant therapy is indicated. These are directly applicable to care
administered by anesthesia providers, also they serve as a resource for other physicians and personnel who are involved in
the perioperative care of these patients.
The Joint Commission59
The inherent risks of blood transfusion are evidenced by the focus on transfusion therapy safety by The Joint Commission
which has identified hemolytic transfusion reaction due to ABO incompatibility as a reviewable sentinel event.
In its 1999 Sentinel Event Alert, The Joint Commission outlined its review of 12 cases related to transfusion errors; a root
cause analysis was completed for each of the events reviewed. Ten of these cases resulted in patient deaths; 11 of the cases
were hemolytic reactions; and one was an infectious reaction. Eleven of the transfusion reactions took place in a general
hospital with eight occurring in a high-risk area, including the OR. The causes of these events included incomplete patient/
blood verifications; handling or processing of blood samples or blood units for more than
one patient at the same time in the same location; and failures to follow established procedures, usually involving the
verification of patient identity and correct blood unit for that patient.
The Joint Commission noted that virtually all of the processes involved in blood transfusion exhibit factors recognized to
increase the risk of an adverse outcome, such as:
●● Variable input, i.e., patients have different blood types.
●●
●●
●●
18
Complexity. This includes the technical aspects of cross matching, as well as administering and monitoring the effects
of blood.
Inconsistency. Despite efforts to clearly define procedures within a health care facility, there is no standardization
across all facilities.
Tight coupling. When the steps involved in a process occur so closely together, a failure in one step leaves little
opportunity for intervention. Furthermore, it is difficult to interrupt the sequence of the process, especially in the OR.
●●
●●
Human intervention, particularly in processes that require a higher level of consistency than is reasonably achievable
by health care workers without computer support.
Tight time constraints, especially in a high-risk area, such as the OR.
Root causes of these sentinel events were categorized into the following six general areas:
●● Patient assessment such as incomplete patient/blood verification and not recognizing the signs and symptoms of a
transfusion reaction.
●●
●●
Care planning, i.e., no informed consent for a blood transfusion.
Laboratory procedures, such as multiple samples cross matched at the same time or a cross match being started
before the order was received.
●●
Staff-related factors, including insufficient orientation, training, or staffing levels.
●●
Equipment-related factors, i.e., blood for multiple surgical patients being stored together in the same refrigerator.
●●
Information-related factors, e.g., incomplete communication among caregivers or errors related to patient identification
band, specimen label or blood label.
Risk reduction strategies suggested in this report included:
●● People-focused actions that include in-service training on transfusion-related procedures and revising the staffing
model.
●●
Process redesign issues such as revising the patient identification band procedures; revising patient/blood verification
procedures; revising and implementing new informed consent procedures; and discontinuing the use of the room
number as the patient identifier.
●●
Technical system redesign efforts, such as enhanced computer support or new patient identification band system.
●●
Environmental redesign issues, e.g., discontinuing use of an OR refrigerator for storage of multiple blood units.
●●
Not using the patient’s room number to identify blood samples or transfusion units.
●●
Considering the use of “unique” identification bands for patients receiving blood transfusions.
●●
Introducing a computerized verification step into the process.
More recent data from The Joint Commission indicates a decline in the number of sentinel events related to blood
transfusion error (see Table 3).60
Table 3 - Summary Data: Transfusion Error Sentinel Events Reviewed by The Joint Commission
Type of
2004 –
Sentinel Event
June 30, 2011
Transfusion Error
Total
86
2009
2010
January –
June 30, 2011
12
5
8
19
In 2009, a new element was added to Goal 1 of The Joint Commission’s National Patient Safety Goal (NPSG) related to
improving the accuracy of patient identification.61 NPSG.01.03.01 requires hospitals to “Eliminate transfusion errors related
to patient misidentification.” The elements of performance include:
●● Before initiating a blood or blood component transfusion:
o Match the blood or blood component to the order.
o Match the patient to the blood or blood component.
o Use a two-person verification process or a one-person verification process accompanied by automated
identification technology, such as bar coding.
●●
●●
When using a two-person verification process, one individual conducting the identification verification is the qualified
transfusionist who will administer the blood or blood component to the patient.
When using a two-person verification process, the second individual conducting the identification verification is
qualified to participate in the process, as determined by the hospital.
REVIEW OF THE LITERATURE: CLINICAL STUDIES ON BLOOD TRANSFUSION METHODS
IN ORTHOPAEDIC SURGICAL PATIENTS
Based on the risks associated with transfusion of allogeneic blood, numerous studies have been conducted over the past 20
years to examine the clinical benefits and patient outcomes related to the use of the various autologous blood transfusion
methods in reducing the need for allogeneic blood transfusion in major orthopaedic procedures. Several of these studies are
summarized below.
As early as 1991, the safety and efficacy of postoperative autologous blood salvage and reinfusion were reported. In this
study of 40 patients undergoing primary unilateral TKA, only 35% of the patients in the study group who received reinfusion
of salvaged blood postoperatively required a homologous blood transfusion, as compared to 95% of patients in the control
group who did not receive postoperative reinfusion of salvaged autologous blood.62
In 2003, a randomized, prospective study of the use of allogeneic blood was performed in 83 patients who underwent
primary TKA and received autologous transfusion either from one unit of predonated autologous blood or from postoperative
unwashed blood salvage.63 The patients in the blood salvage group did not predonate blood, but only received reinfusion
of the salvaged blood from a sterile, low continuous suction device during the first 6 hours postoperatively. No significant
difference was seen between the groups in the prevalence of allogeneic blood transfusion: 5% for the predonation group
and 0% for salvage group. The authors concluded that autologous blood from unwashed postoperative salvage from the
drain was as effective as predonated autologous blood in preventing the need for and the risks associated with allogeneic
blood after TKA. Based on these results, the authors further commented:
●●
●●
The need for the surgeon to schedule patients for blood predonation, delaying the procedure, and the inconvenience
for patients to travel to the blood bank and take oral iron or erythropoietin would be eliminated by the use of
postoperative blood salvage.
The average preoperative hematocrit was significantly lower in patients who predonated autologous blood than in
patients in the study group.
A 2005 study of 229 TKA and THA patients assessed the results of both postoperative and intraoperative blood salvage
to determine if both salvage methods reduced allogenic blood transfusion.64 The study group of TKA patients received the
salvaged blood postoperatively; the study group of THA patients received the salvaged blood intraoperatively. The results
of this study demonstrated that the patients who received postoperatively salvaged blood after TKA generally had higher
postoperative hemoglobin and hematocrit levels than those who did not. For the THA patients, postoperative hemoglobin
and hematocrit levels were similar in both groups who received and did not received salvaged blood. These authors
20
concluded that while the incidence of allogeneic blood transfusion was not reduced in TKA patients who received salvaged
blood, the reinfusion of salvaged blood may reduce the number of allogeneic units used. Further, in light of the short supply
of allogenic blood and its associated risks, both intraoperative and postoperative blood salvage have clear advantages.
More recently, a retrospective review to compare three blood management strategies in 154 patients undergoing TKA
was conducted. Primarily, this review evaluated whether a single change in the clinical blood management of patients
undergoing TKA reduced the severity of postoperative anemia or the need for allogeneic blood transfusions; also, it
assessed the financial impact of a change on the facility.65 This study compared perioperative cell salvage, preoperative
autologous blood donation, and the practice of using allogeneic blood alone in patients undergoing TKA. Transfusion
rates were 25%, 18%, and 52% respectively for patients in the cell salvage, preoperative autologous blood donation,
and allogeneic blood only groups. Respective relative risk reductions were 51.9% and 65.4% with the use of cell salvage
or preoperative autologous blood donation versus allogeneic blood transfusions alone. Cell salvage and preoperative
autologous blood donation were found to significantly reduce the requirements for allogeneic blood transfusions; in addition,
these techniques roughly were found to be equivalent in clinical benefit when compared to the use of allogeneic blood
alone. However, the logistical advantages of cell salvage (i.e., no preoperative blood donation, no risk of wasting blood
units) were associated with greater costs to the facility.
Another study examined the efficacy of two different autotransfusion methods in TKA performed without tourniquet use, in
comparison to allogeneic blood transfusion (ABT) only.66 In this comparative study, 248 patients with knee osteoarthritis
were randomized in three groups: in the Control Group, 85 of the patients underwent only ABT postoperatively (according
to predetermined criteria); in Group 1 (92 patients), an intraoperative and postoperative autotransfusion were utilized; and
in Group 2 (71 patients), only a postoperative autotransfusion was used. Comparing the Control Group to Groups 1 and
2, the difference in need for ABT postoperatively was statistically highly significant, even when the results were analyzed
classifying the patients according to the preoperative hemoglobin levels; however, the difference between Group 1 and
2 was not significant. According to the results of this study, auto-transfusion reduces the need for ABT in TKA that is
performed without the use of a tourniquet.
A recent study of 61 adolescent idiopathic scoliosis patients who underwent posterior fusion was conducted to determine
the clinical characteristics of perioperative blood loss during the procedure and also to examine the effectiveness of
homologous blood transfusion and intraoperative cell salvage.67 Both homologous blood transfusion and intraoperative cell
salvage were used in all cases; allogeneic transfusion was not given in any of the cases. The results of this study showed
that the perioperative estimated blood loss correlated with the extent of fused vertebrae during the procedure as well as
the length of the procedure. The authors concluded that homologous transfusion and intraoperative cell salvage were
considered to be effective strategies to avoid the need for allogeneic blood transfusion in these patients.
In a prospective study designed to evaluate the effectiveness of postoperative autotransfusion in preventing the need
for allogeneic blood transfusion, 74 patients who underwent hip and knee arthroplasty procedures were randomized into
control and study groups.68 The preoperative and postoperative hemoglobin and hematocrit levels did not differ significantly
between the groups. In the knee group, cemented, bicompartmental arthroplasty was performed under tourniquet control;
in the hip group, cementless arthroplasty with a posterolateral approach was performed. The salvaged blood in the surgical
area was transfused with an 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 given to patients with a hemoglobin level below 8 g/dL, a hematocrit level below 25%, and
clinical symptoms of anemia. Allogeneic blood transfusion was given to one patient in the study group and 8 patients in the
control group during knee arthroplasty; whereas, 9 patients in the study group and 15 patients in the control group received
allogeneic blood transfusion during hip arthroplasty. The amount of allogeneic blood transfusion in both study groups was
significantly lower than that in the control groups. Based on these results, the authors concluded that the need for and
amount of allogeneic transfusion were reduced with postoperative autotransfusion in both the knee and hip arthroplasty
groups, and to a greater extent, in knee arthroplasty.
21
A report of experience with autotransfusion of blood recovered from the postoperative wounds in 178 patients after total hip
or knee arthroplasty demonstrated that autotransfusion of blood recovered from the postoperative wounds in these patients
makes it possible to avoid the transfusion of allogeneic blood products and also reduces the postoperative decrease in
hemoglobin levels.69 The same autotransfusion system was used to recover and then auto-transfuse the blood collected
from the surgical wound postoperatively. Hemoglobin and hematocrit levels were determined in all patients before surgery
and then at 6 and 12 hours postoperatively. For the entire group of 178 patients, 64,600 ml of blood was recovered by
draining the postoperative wound; of these, 112 (62.9%) patients did not require additional transfusion of allogeneic blood.
SUMMARY
Blood loss during major orthopaedic surgical procedures can be extensive, putting the patient at high risk for postoperative
anemia; therefore, the need for allogeneic blood transfusion is a common requirement. However, concerns related to
the safety of allogeneic blood and the associated risks of exposure (i.e., infection, transfusion-transmitted diseases, fluid
overload, and longer hospital stays) have prompted increasing interest in alternative blood management strategies. Today,
these alternative strategies are playing an increasing role in effective perioperative blood management for orthopaedic
surgical patients.
This course has reviewed four blood transfusion therapy options for orthopedic surgical procedures:
●● allogeneic or banked blood
●●
preoperative autologous blood donation
●●
intraoperative blood salvage
●●
postoperative blood salvage
The use of autologous techniques can reduce or eliminate the exposure of these patients to allogeneic blood. Although
currently the risks of adverse events related to transfusion with allogeneic blood are low, transfusion of autologous blood
remains a safer option.
While various guidelines and standards have been published for perioperative blood management, an effective strategy
must consider both the patient and the surgical procedure, assess the transfusion risks, and formulate a plan to address
them appropriately. Autologous blood transfusion techniques should be used for eligible patients who are likely to require
transfusion, but it should not be started for procedures in which transfusion is unlikely. With individualized and careful
planning, as well as a team approach, many problems associated with autologous donations and blood salvage procedures
may be avoided, thereby ensuring safe transfusion practices for orthopaedic surgical patients.
22
GLOSSARY
Alloantibody
Allogeneic Blood
Angioedematous Reactions
Anticoagulant
Apheresis
Autologous Blood
Autotransfusion
Centrifuge
Citrate Phosphate Dextrose (CPD)
Coagulopathy
Defibrinogenate
2,3-Diphosphoglycerate
Embolism
Erythrocytes
Erythropoietin
Hematoma
Hemoglobin (Hgb)
Hematocrit (Hct)
Hemodilution
An antibody produced or derived from one individual that reacts with the
alloantigens of another individual of the same species; also called an
isoantibody.
Blood donated by someone other than the patient for transfusion.
Vascular reactions similar to hives that affect the deep dermis or
subcutaneous or submucosal tissues; these reactions represent localized
edema due to dilation and increased permeability of the capillaries and
are characterized by giant elevated patches. Angioedema and hives can
occur separately or simultaneously.
An agent or substance that prevents the formation of a blood clot or
coagulation; commonly used anticoagulants are CPD (see below) and
heparin.
The process of removing one or more specific component from a unit of
whole blood.
Blood that a patient donates for his/her own used for transfusion.
A procedure in which blood is collected from a patient and reinfused into
the same patient’s circulation; also known as autologous transfusion.
The process of fractionating whole blood, i.e., separating it into its
component parts; after the process, RBCs remain at the bottom of the
centrifuge tube.
A combined solution of citrate, phosphate, and dextrose that prevents
blood coagulation or clotting. Adenine may be added to increase red
blood cell storage time.
Any disorder of blood coagulation, which either results in excessive
clotting or insufficient clotting. The presence of a high anticoagulant
concentration can lead to insufficient clotting or excessive bleeding.
To remove clots from the blood.
A substance made in the red blood cells. It controls the movement of
oxygen from red blood cells to body tissues.
The obstruction or occlusion of a blood vessel by a foreign substance, an
air bubble, or detached blood clot that travels through the bloodstream
and lodges so as to block the vessel.
Red blood cells (RBCs).
A hormone, produced primarily by the kidneys, that stimulates the
production of red blood cells by stem cells in the bone marrow, it is
released in response to decreased levels of oxygen in body tissue.
An abnormal, localized collection of clotted or partially clotted blood that
accumulates in an organ, tissue, or body space as the result of leakage
from a broken blood vessel.
The iron-containing, protein in red blood cells that carries oxygen from the
lungs to the body tissues.
The percentage of blood that is comprised of red blood cells; it is
expressed as a percentage by volume, i.e., the ratio of red blood cells to
the total volume of blood.
An increase in the volume of plasma, resulting in a reduced concentration
of red blood cells in the blood.
23
Hemolysis
Heparin
Homologous
Homologous Blood
Hypervolemia
Hypofibrinogenemia
Immunomodulation
Intraoperative Blood Salvage
Micoembolus
Platelet
Postoperative Autotransfusion
Postoperative Blood Salvage
Preoperative Autologous Blood Donation
Procoagulant
Sickle Cell Disease
Thalassemia
Thrombocytopenia
Urticaria
24
The destruction of red blood cells which leads to the release of
hemoglobin from within the red blood cells into the plasma.
A complex organic acid, found in lung and liver tissue, which has the
ability to prevent the clotting of blood.
Having a similar structure or other critical attributes.
Blood transfused from one individual to another of a different genetic
make-up; it may be stored or banked blood.
Fluid overload; an excessive accumulation of fluid in the body caused by
excessive parenteral infusion or deficiencies in cardiovascular or renal
fluid volume regulation.
A reduction of fibrinogen in the blood; the deficiency of fibrinogen may
be congenital or it may result from faulty synthesis associated with liver
disease and defibrinogenation resulting from disorders of pregnancy
involving the placenta and amniotic fluid.
A change in the body’s immune system caused by agents that activate or
suppress its function.
A procedure during which blood lost in surgery is recovered and reinfused
into the patient.
An embolus of microscopic size, e.g., a tiny blood clot, air bubble, mass of
cells, fat particle, etc. that travels through the bloodstream, and lodges in
a blood vessel thereby obstructing it.
A minute, irregularly shaped, disk found in blood plasma that promotes
blood clotting; it has no definite nucleus, no DNA, and no hemoglobin. It
releases the enzyme thrombin as a resin, which causes coagulation of the
blood; also it is called a thrombocyte.
The collection and reinfusion of the patient’s blood which is shed from
wound drainage devices following major orthopaedic procedures, e.g.,
joint arthroplasty.
The process of collecting blood after a surgical procedure by drainage of
the operative area and then reinfusing it to the patient.
The process in which units of blood are drawn from a patient, usually
starting (in the short term case) three to five weeks prior to an elective
surgical procedure and then stored for transfusion at the time of surgery.
The precursor of any of the various blood factors necessary for
coagulation; an agent that promotes the coagulation of blood.
A group of inherited blood disorders characterized by chronic anemia
and various complications due to associated tissue and organ damage.
Because sickle cell diseases are characterized by the rapid loss of RBCs
as they enter the circulation, they are classified as hemolytic disorders.
A group of inherited disorders characterized by reduced or absent
amounts of hemoglobin; these conditions cause varying degrees of
anemia, ranging from insignificant to life threatening.
An abnormal reduction in the number platelets in circulating blood.
A vascular reaction of the upper dermis marked by a transient appearance
of slightly elevated patches, which are either redder or paler than the
surrounding skin and often attended by severe itching.
REFERENCES
1. Tobias JD. Strategies for minimizing blood loss in orthopedic surgery. Seminars in Hematology. 2004; 41(1Suppl1): 145156.
2. Sehat KR, Evans RL. Hidden blood loss following hip and knee arthroplasty. Journal of Bone and Joint Surgery. British
Volume. 2004;86 (4):561-565.
3. Peak EL, Hozack WJ, Sharkey PF, Parvizi J, Rothman RH. One-stage bilateral total joint arthroplasty: A prospective,
comparative study of total hip and total knee replacement. Orthopedics. 2008;31(2):131.
4. Sinclair KC, Clarke HD, Noble BN. Blood management in total knee arthroplasty: A comparison of techniques.
Orthopedics. 2009;32(2):19.
5. Millett PJ, Porramatikul M, Chen N, Zurakowski D, Warner JJ. Analysis of transfusion predictors in shoulder
arthroplasty. Journal of Bone and Joint Surgery. British Volume. 2006;88 (6): 1223-1230.
6. Blanchette CM, Joshi AV, Szpalski M, Gunzburg R, DuBois M, Donceel P, Saunders WB. Comparison between spinal
surgery blood transfusion services costs and associated treatment practices in the United States and Belgium. Current
Medical Research and Opinions. 2007;23(11):2793-2804.
7. Moonen AF, Neal TD, Pilot P. Peri-operative blood management in elective orthopaedic surgery. A critical review of the
literature. Injury. 2006;37S:S11–S16.
8. Tobias JD. Strategies for minimizing blood loss in orthopedic surgery. Seminars in Hematology. 2004; 41(1Suppl1): 145156.
9. Normal lab values. Available at: http://www.meditec.com/resourcestools/medical-reference-links/normal-lab-values/.
Accessed August 15, 2011.
10. Normal lab values. Available at: http://www.meditec.com/resourcestools/medical-reference-links/normal-lab-values/.
Accessed August 15, 2011.
11. Normal lab values. Available at: http://www.meditec.com/resourcestools/medical-reference-links/normal-lab-values/.
Accessed August 15, 2011.
12. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature,
2nd Ed; 2007. Available at: http://www.sld.cu/galerias/pdf/sitios/anestesiologia/practical_guidelines_blood_transfusion.
pdf. Accessed August 15, 2011.
13. 2-3-diphosphoglycerate test. Available at: http://medical-dictionary.thefreedictionary.com/2,3-diphosphoglycerate+test.
Accessed August 15, 2011.
14. Barr PJ, Donnelly M, Cardwell C, Alam SS, Morris K, Parker M, Bailie KE. Drivers of transfusion decision making and
quality of the evidence in orthopedic surgery: a systematic review of the literature. Transfusion Medicine Reviews. 2011
June 1 [Epub ahead of print].
15. Murphy EK. Patient safety and risk management. Alexander’s Care of the Patient in Surgery. 14th Ed. St. Louis, MO:
Elsevier Mosby; 2011: 40.
16. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature,
2nd Ed; 2007. Available at: http://www.sld.cu/galerias/pdf/sitios/anestesiologia/practical_guidelines_blood_transfusion.
pdf. Accessed August 15, 2011.
25
17. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature,
2nd Ed; 2007. Available at: http://www.sld.cu/galerias/pdf/sitios/anestesiologia/practical_guidelines_blood_transfusion.
pdf. Accessed August 15, 2011.
18. ASA. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American
Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology.
2006;105:198-208.
19. ASA. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American
Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology.
2006;105:198-208.
20. AABB. Highlights of transfusion medicine history. Available at: http://www.aabb.org/resources/bct/Pages/highlights.aspx.
Accessed August 16, 2011.
21. AABB. Blood FAQs. Available at: http://www.aabb.org/resources/bct/Pages/bloodfaq.aspx. Accessed August 16, 2011.
22. AABB. Testing of donor blood for infectious disease. Available at: http://www.aabb.org/resources/bct/bloodfacts/Pages/
fabloodtesting.aspx. Accessed August 16, 2011.
23. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature,
2nd Ed; 2007. Available at: http://www.sld.cu/galerias/pdf/sitios/anestesiologia/practical_guidelines_blood_transfusion.
pdf. Accessed August 15, 2011.
24. American Red Cross. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature,
2nd Ed; 2007. Available at: http://www.sld.cu/galerias/pdf/sitios/anestesiologia/practical_guidelines_blood_transfusion.
pdf. Accessed August 15, 2011.
25. AABB. The 2009 National Blood Collection and Utilization Survey Report. Available at: http://www.aabb.org/programs/
biovigilance/nbcus/Documents/09-nbcus-report.pdf. Accessed August 16, 2011.
26. AABB. The 2009 National Blood Collection and Utilization Survey Report. Available at: http://www.aabb.org/programs/
biovigilance/nbcus/Documents/09-nbcus-report.pdf. Accessed August 16, 2011.
27. Henry DA, Carless PA, Moxey AJ, O’Connel D, Forgie MA, Wells PS, Fergusson D. Pre-operative autologous
donation for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Review.
2002;2:CD003602.
28. Wass CT, Long TR, Faust RJ, Yaszeski MJ, Joyner MJ. Changes in red blood cell transfusion practice during the
past two decades: A retrospective analysis, with Mayo database, of adult patients undergoing major spine surgery.
Transfusion. 2007;47:1022-1027.
29. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. Nurse Anesthesia. 4th Ed. St. Louis, MO:
Saunders Elsevier; 2010: 417-418.
30. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
31. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
32. AABB. Standards for Perioperative Autologous Blood Collection and Administration. 4th ed. Bethesda, MD: AABB;
2009.
26
33. Goodnough LT, Monk TG. Autologous transfusion. In Miller’s Anesthesia, 6th ed. RD Miller, ed. Philadelphia, PA:
Elsevier; 2005; 1831-44.
34. Lichtman MA, Beutler E, Kipps TJ, Seligsohn U, Kaushansky K, Prchal JT. Williams Hematology, 7th Edition. The
McGraw-Hill Companies, Inc. 2006.
35. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. Nurse Anesthesia. 4th Ed. St. Louis, MO:
Saunders Elsevier; 2010: 417-418.
36. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
37. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. Nurse Anesthesia. 4th Ed. St. Louis, MO:
Saunders Elsevier; 2010: 417-418.
38. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
39. Waters JH. Indications and contraindications of cell salvage. Transfusion. 2004; 44(12 Suppl): 40S-44S.
40. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
41. Goodnough LT, Monk TG. Autologous transfusion. In Miller’s Anesthesia, 6th ed. RD Miller, ed. Philadelphia, PA:
Elsevier; 2005; 1831-44.
42. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. Nurse Anesthesia. 4th Ed. St. Louis, MO:
Saunders Elsevier; 2010: 418.
43. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
44. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. Nurse Anesthesia. 4th Ed. St. Louis, MO:
Saunders Elsevier; 2010: 418.
45. AABB. Autologous (self-donated) blood as an alternative to allogeneic (donor-donated) blood transfusion. Available at:
http://www.aabb.org/resources/bct/bloodfacts/Pages/fabloodautoallo.aspx. Accessed August 17, 2011.
46.
Muñoz M, García-Vallejo JJ, Ruiz MD, Romero R, Olalla E, Sebastián C. Transfusion of post-operative shed blood:
laboratory characteristics and clinical utility. European Spine Journal. 2004;13 Suppl 1:S107-13.
47. Muñoz M, García-Vallejo JJ, Ruiz MD, Romero R, Olalla E, Sebastián C. Transfusion of post-operative shed blood:
laboratory characteristics and clinical utility. European Spine Journal. 2004;13 Suppl 1:S107-13.
48. Zacharopoulos A, Apostolopoulos A, Kyriakidis A. The effectiveness of reinfusion after total knee replacement. A
prospective randomized controlled study. International Orthopaedics. 2007;31(3):303-308.
49. Mirza SB, Campion J, Dixon JH, Panesar SS. Efficacy and economics of postoperative blood salvage in patients
undergoing elective total hip replacement. Annals of the Royal College of Surgeons of England. 2007;89 (8):777-784.
50. Muñoz M, Kühlmorgen B, Ariza D, Haro E, Marroquí A, Ramirez G. Which patients are more likely to benefit from
postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures.
Vox Sanguinis. 2007;92(2):136-141.
27
51. Lichtman MA, Beutler E, Kipps TJ, Seligsohn U, Kaushansky K, Prchal JT. Williams Hematology, 7th ed. The McGrawHill Companies, Inc. 2006.
52. Muñoz M, García-Vallejo JJ, Ruiz MD, Romero R, Olalla E, Sebastián C. Transfusion of post-operative shed blood:
laboratory characteristics and clinical utility. European Spine Journal. 2004;13 Suppl 1:S107-13.
53. Horst HM, Dlugos S, Fath JJ, Sorensen VJ, Obeid FN, Bivins BA. Coagulopathy and intraoperative blood salvage
(IBS). Journal of Trauma. 1992;32 (5):646-562.
54. AABB. Standards for Perioperative Autologous Blood Collection and Administration. 4th ed. Bethesda, MD: AABB;
2009.
55. Intravascular therapy. Nursing Procedures & Protocols. Available at: http://books.google.com/books?id=WEAP8q-us
VcC&pg=PA167&lpg=PA167&dq=nursing+procedures+for+intraoperative+blood+salvage&source=bl&ots=rAU3NEY
3uM&sig=rSuSGuIfIUvYSVB2tS-Tj8A7Nrk&hl=en&ei=mp1NTr_SDaT-sQL1_ZCLBw&sa=X&oi=book_result&ct=resu
lt&resnum=4&ved=0CDMQ6AEwAw#v=onepage&q=nursing%20procedures%20for%20intraoperative%20blood%20
salvage&f=false. Accessed August 18, 2011.
56. US FDA. CFR - Code of Federal Regulations Title 21Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/
cfcfr/CFRSearch.cfm. Accessed August 17, 2011.
57. AABB. Standards for Perioperative Autologous Blood Collection and Administration. 4th ed. Bethesda, MD: AABB;
2009.
58. ASA. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American
Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology.
2006;105:198-208.
59. The Joint Commission. Sentinel Event Alert. Issue 10 - August 30, 199. Blood transfusion errors: preventing future
occurrences. Available at: http://www.jointcommission.org/assets/1/18/SEA_10.pdf. Accessed August 18, 2011.
60. The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission. Available at:
http://www.jointcommission.org/assets/1/18/SE_Stats_Summary_2Q_20111.PDF. Accessed August 18, 2011.
61. The Joint Commission. Accreditation Program: Hospital National Patient Safety Goals Effective January 1, 2011. Available at: http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed August 18, 2011.
62. Majkowski RS, Currie IC, Newman JH. Postoperative collection and reinfusion of autologous blood in total knee
arthroplasty. Annals of the Royal College of Surgeons of England. 1991; 73(6): 381-384.
63. Woolson ST, Wall WW. Autologous blood transfusion after total knee arthroplasty: a randomized, prospective study
comparing predonated and postoperative salvage blood. The Journal of Arthroplasty. 2003; 18(3): 243-249.
64. Jain R, Jain S. Blood salvage in total hip and knee arthroplasty in a community hospital: a retrospective study. Journal
of Orthopaedic Surgery. 2005;13: 19-26.
65. Sinclair KC, Clarke HD, Noble BN. Blood management in total knee arthroplasty: a comparison of techniques.
Orthopedics. 2009; 32(1): 19.
66. Blatsoukas KS, Drosos GI, Kazakos K, Papaioakim M, Gioka T, Chloropoulou P, Verettas DA. Prospective comparative
study of two different autotransfusion methods versus control group in total knee replacement. Archives of Orthopaedic
and Trauma Surgery. 2010; 130(6): 733-737.
28
67. Doi T, Harimaya K, Matsumoto Y, Taniguchi H, Iwamoto Y. Peri-operative blood loss and extent of fused vertebrae in
surgery for adolescent idiopathic scoliosis. Fukuoka Igaku Zasshi. 2001; 102(1): 8-13.
68. Atay EF, Güven M, Altintas F, Kadioğlu B, Ceviz E, Ipek S. Allogeneic blood transfusion decreases with postoperative
autotransfusion in hip and knee arthroplasty. Acta Orthopaedica Traumatologica Turcica. 2010;44(4):306-312.
69. Rojewski M, Krol R, Krzykawski R, Prochacki P. Value of the autotransfusion of blood recovered from the post-operative
wound in arthroplasty patients. Ortopedia Traumatologia, Rehabilitacja. 2009; 11(5): 448-457.
29
Please close this window and
return to the main page to proceed
with taking the online test, evaluation
and registration.
30