➢ In contemporary practice, the prevalence of blood transfusion after unilateral primary joint arthroplasty should be ≤10%.
➢ The traditional hemoglobin threshold for red blood-cell transfusion (i.e., <10 g/dL) should be abandoned; patients who are not actively bleeding tolerate a hemoglobin level of >7 g/dL and those with cardiac risk factors tolerate a hemoglobin level of >8 g/dL without major risk of additional morbidity or mortality.
➢ Many symptoms that are traditionally attributed to postoperative anemia, including dizziness, orthostatic hypotension, tachycardia, and low urine output, often represent a volume-depletion problem that will respond to intravenous fluid administration without the need for red blood-cell transfusion; while intravascular volume repletion with crystalloids may result in hemodilution, there is little change in circulating red blood-cell mass.
➢ Antifibrinolytic therapy is clinically efficacious, cost-effective, and safe for broad groups of patients; most studies have excluded patients with substantial risk factors for thromboembolic disease, making definitive statements about safety in those patients tentative.
➢ The cornerstones of contemporary blood management for patients undergoing total joint arthroplasty include preoperative screening for anemia, perioperative antifibrinolytic therapy, postoperative fluid resuscitation before transfusion, and elimination of the traditional 10/30 transfusion trigger (hemoglobin, <10 g/dL; hematocrit, <30%).
Despite advances in surgical technique and perioperative care, blood loss after elective joint arthroplasty remains an issue. Historical averages for the decrease in hemoglobin (Hb) after unilateral total knee arthroplasty and total hip arthroplasty are approximately 3 to 4 g/dL1 because of a combined effect of blood loss and hemodilution. Greater blood loss may occur after bilateral or revision surgery.
Transfusion of blood products has long been the mainstay of postoperative anemia treatment. With other factors being equal, a higher hemoglobin level is beneficial postoperatively. However, the most effective means to obtain these levels must be examined. Allogeneic transfusions carry certain risks, such as disease transmission and reactions2, clerical error, and infection3-5. With each subsequent unit of red blood cells transfused, the risk of a complication increases, and minimizing allogeneic transfusion is of particular importance6. Moreover, oxygen content may be adversely affected by blood product storage, as evidenced by decreased levels of 2,3-diphosphoglycerate7 and vasoinhibitory effects8. This relatively poor quality of banked blood is problematic9 and undermines the goal of increasing oxygen delivery with allogeneic transfusions. Transfusions also substantially increase the length of stay4, interfere with therapy, and deliver an inherently negative psychological impact and perception of illness. With fixed blood bank resources and administration costs10,11, transfusions drive hospital admission costs 10% to 20% higher12.
Based on current practices, orthopaedists should reexamine the “10/30 rule” of 1942, which suggests transfusion for a hemoglobin level of <10 g/dL and a hematocrit of <30%13. Historical transfusion rates have been as high as 59% following revision total hip arthroplasty14. Blood management for patients undergoing hip and knee arthroplasty is defined by the goals of ensuring appropriate circulating volume and minimizing routes for blood loss. Avoiding allogeneic transfusion and its attendant risks is a byproduct of this philosophy.
Several key advances and a development in our understanding of blood management have shaped the way that we should view transfusions and practice variability15. The current review evaluates these techniques, pharmaceuticals, and tools. It is divided into strategies that are applicable in the preoperative, intraoperative, and postoperative periods. It should be noted that the associated end points of blood management strategies vary throughout the perioperative course. For example, while host optimization and adequate blood volume and hemoglobin concentration are important in the preoperative period, tools and techniques to limit blood loss gain importance in the intraoperative period. Ultimately, the goal of blood management strategies is to reduce morbidity and mortality following elective joint arthroplasty. A summary of trends and effectiveness of each strategy is found in Table I.
The hemoglobin level can affect the quickness of recovery16, although most of the data used to support this premise are qualitative. Perioperative risks are associated with a lower preoperative hemoglobin level, especially in patients with a history of cardiac disease17. Baseline anemia is more prevalent with increasing age18. More than one-third of patients who are managed with arthroplasty have a baseline hemoglobin level of <13 g/dL14, and a systematic review demonstrated anemia rates of 24% to 44%19.
A strong predictor of transfusion has been a lower preoperative hemoglobin level, with <13 g/dL being a common historical threshold14. Hatzidakis et al. found that patients with a hemoglobin level of >15 g/dL and those who were less than sixty-five years old with a hemoglobin level of 13 to 15 g/dL did not require transfusion20. Other predictive factors include revision or bilateral surgery, increasing age21, and preoperative autologous donation22. The preoperative hemoglobin level combined with estimated blood loss has been used for prediction23. Keating and Ritter presented an algorithm based on the likelihood of transfusion24. Despite this and other prediction tools25 based on historical rates of transfusion, the optimum transfusion threshold itself has yet to be determined and is likely lower with evolving blood management strategies. Other special circumstances include a “bloodless program” for Jehovah’s Witness patients26. One must carefully delineate available management options.
Epoetin Alpha (Recombinant Human Erythropoietin)
The glycoprotein erythropoietin stimulates hemoglobin synthesis27 in response to hypoxia28. Epoetin alpha is a synthetic analog with extensive use in non-orthopaedic populations29. Other forms of recombinant erythropoietin have been tested in Europe in patients undergoing arthroplasty30. By raising preoperative hemoglobin levels31, epoetin benefits patients who refuse to or cannot predonate32. Epoetin also may benefit patients with anemia due to chronic disease or rheumatoid arthritis33 or as an adjunct to autologous donation34. An early use in orthopaedics was in the setting of revision total hip arthroplasty in Jehovah’s Witness patients35. Epoetin therapy may have an important role in two-stage reimplantation36,37.
Previous studies have demonstrated the superiority of epoetin over placebo38 as well as the safety of epoetin, with no increased risk of thromboembolic disease39. Epoetin has been reported to be as effective as preoperative autologous donation with regard to the risk of transfusion40. In conjunction with iron supplementation, it can increase the number of preoperative autologous donation units produced41. Subcutaneous administration allows for weekly dosing42.
Iron is important in the erythropoietic response43. Supplementation may be especially useful to augment preoperative autologous donation44 or as an adjunct to epoetin therapy45. In a study of patients undergoing total hip arthroplasty, supplementation was equivalent to preoperative autologous donation with regard to transfusion risk46. In 2011, a meta-analysis demonstrated supplementation to be safe for elderly patients undergoing hip and knee procedures, with an increase in hemoglobin but no difference in transfusion47. Because the amount of iron absorbed with oral supplementation is reduced, current regimens include 150 to 200 mg of oral ferrous sulfate (approximately 65 mg of elemental iron) three times daily48,49. Depending on the degree of anemia, supplementation may be initiated as early as four to six weeks preoperatively50 and may be continued for three to six weeks postoperatively51.
Preoperative Holding of Anticoagulants
Common anticoagulants include antiplatelet medications (aspirin, clopidogrel), warfarin, nonsteroidal anti-inflammatory medications, and, more recently, oral factor Xa and thrombin inhibitors. When used for the purpose of chronic anticoagulation for patients with cardiac dysrhythmia, valvular disease, or implanted stents, the risks of holding medications must be weighed against complications related to a hypercoagulable state perioperatively52,53. Recent small series of patients with hip fractures demonstrated no differences in terms of operative blood loss54 or units transfused55 with continuation of clopidogrel perioperatively. Rhodes et al. reported on the apparent safety of elective total knee arthroplasty in patients who continued to receive warfarin therapy throughout the perioperative period56.
Consultation with vascular, cardiology, and/or hematology colleagues may result in bridging therapy. Elective joint arthroplasty may need to be delayed in the setting of recent myocardial infarction or insertion of a drug-eluting stent57. Selective and nonselective cyclooxygenase and prostaglandin synthetase inhibitor drugs work at various stages in the metabolism of arachidonic acid. Reversible cyclooxygenase inhibitors with short-term antiplatelet effects may be stopped closer to the time of the operation but may result in a rebound pain effect58. Holding certain herbal and dietary supplements, such as ginkgo biloba59, avoids potential deleterious coagulation effects and drug-drug interactions.
Preoperative Autologous Donation
Preoperative autologous donation is generally performed three to five weeks before an operation60. Patients with advanced cardiac disease should avoid donating61. A predonation hemoglobin level of >11 g/dL is generally required, and the patient should weigh >50 kg62. Donating preoperatively has been shown to reduce the risk of deep venous thrombosis postoperatively63. Despite more stringent allogeneic blood screening, perceptions regarding the superior safety of autologous donation persist64. However, preoperative autologous donation is not without risks, including transfusion reactions (e.g., febrile syndromes, coagulopathy, hemolysis, lung injury)65, clerical errors66, bacterial contamination67, ischemic events68, and immunosuppresion69.
Donation effectively creates a state of anemia. Stimulation of erythropoiesis remains a function of predonation hemoglobin level and iron stores70 as well as the degree of tissue oxygen desaturation. An often inadequate compensatory increase in hemoglobin is seen after preoperative autologous donation71. Between 40% and 50% of preoperatively donated autologous units are wasted14,72, and up to 70% of units are either unused or inappropriately transfused2,73. This waste adds to the increased cost of preoperative autologous donation as compared with allogeneic blood10, and preoperative autologous donation may be cost-ineffective74.
To better estimate the need for autologous units, a number of investigators have proposed predictive algorithms75-79. While the utility of preoperative autologous donation may be decreasing, offering autologous donation may be required by law in some states80. In a 2009 survey of arthroplasty surgeons, 226 respondents (73%) reported that they did not use preoperative autologous donation for total hip arthroplasty and 267 respondents (85%) reported that they did not do so for total knee arthroplasty81.
Directed (Designated) Donor
Directed donation can decrease the interval of time to the operation when compared with the delays inherent to preoperative autologous donation or epoetin therapy. Despite the notion that donations from family or friends are safer (i.e., despite the bias among patients that sources known to them do not carry disease), the risk of disease transmission actually may be increased82. Between 1989 and 1994, only 2% to 3% of all donations were designated2, and this rate declined in the early 2000s80.
The anecdotal vigor seen after blood transfusion may have advantages in terms of the ability of orthopaedic patients to participate in rehabilitation. When muscle strength has been used as a surrogate for vigor, a correlation has been shown between muscle strength and hematocrit83. It is unclear, however, what role the supplemental volume alone—rather than the red blood-cell products—played in increased exercise tolerance. Most patients function quite safely with relatively low hemoglobin if they have sufficient intravascular volume. Blood transfusions should be the exception, not the norm. Transfusion should be used only after other blood management and volume repletion methods have been exhausted84. This alternate perspective helps to distinguish between the concepts of total intravascular volume and circulating red blood-cell mass. Traditional indicators of the need for transfusion (e.g., orthostatic hypotension, elevated heart rate) almost always respond to crystalloid intravenous fluids. Furthermore, the clinical symptoms of anemia85 overlap closely with those of volume depletion. If crystalloid volume support is given first, the symptoms of volume depletion may be ameliorated without blood product use. Colloid products may provide another effective alternative to allogeneic blood transfusion86,87. As with any fluid resuscitation measure, the patient should be monitored for signs of edema and complications associated with volume overload.
In an experimental setting, healthy humans can tolerate a hemoglobin level as low as 5 g/dL88. While the true tolerable hemoglobin nadir varies across patients, severe anemia (a hemoglobin level of <6 g/dL) has been tolerated in orthopaedic cohorts85. In the study by Carson et al., higher mortality was seen among patients with a hemoglobin level of <6 g/dL as compared with those with a level of >10 g/dL89. In a clinical study of patients with hip fractures, no benefit in terms of mortality was seen in association with transfusion in patients with a hemoglobin level as low as 8 g/dL5. Certainly, no optimum hemoglobin threshold exists for all patients; rather, the threshold is based on multiple factors90.
Acute Normovolemic Hemodilution
This technique involves collecting two to three autologous units immediately preoperatively or while the patient is under anesthesia91. Normovolemia is then maintained with crystalloids and/or colloids to effect a replacement of whole blood with acellular fluids. Acute normovolemic hemodilution may be considered when intraoperative blood loss is likely to exceed 20% of blood volume and the preoperative hemoglobin level is >10 g/dL2. This method has been reported to be efficacious in the setting of joint arthroplasty92 and has been found to be as effective as preoperative autologous donation for reducing the risk of transfusion93. A meta-analysis of forty-two trials demonstrated a modest blood-conservation benefit, but only one-third of the reports included information on adverse events94. Acute normovolemic hemodilution is less costly than preoperative autologous donation95, and a systematic review demonstrated it to be more cost effective than cell salvage96. Hemodilution should be used with caution in the elderly, and it is generally contraindicated for patients with certain conditions such as anemia and coronary artery disease60.
Antifibrinolytic medications have been used for more than five decades in various surgical disciplines, including dentistry and cardiac surgery97. Specific interventions, such as tourniquet and pneumatic compression stocking use, can accelerate fibrinolysis. Antifibrinolytic medications work along the fibrinolytic cascade to prevent the dissolution of established fibrin clots; they are not so-called procoagulant medications. Despite a traditional underusage of antifibrinolytic medications in orthopaedics, the utility and efficacy of these medications has gained recent interest.
Tranexamic acid, a synthetic lysine analog, competitively saturates plasminogen binding sites. This inhibits the activation of plasminogen to plasmin and the subsequent breakdown of fibrin clot98. This drug has a short-term effect (a half-life of two hours), is rapidly excreted in the urine, and preferentially inhibits fibrinolysis in the surgical field as compared with the general circulation99. As of 2009, the U.S. Food and Drug Administration (FDA) indicated tranexamic acid (Cyklokapron; Pfizer, New York, NY) for the prevention of blood loss during tooth extraction in hemophiliacs100. Available in both intravenous and topical formulations, the cost is around $60 to $71 per gram in the United States and $6 per gram in Canada. The recommended dosing is 10 to 20 mg/kg per dose, and multiple doses are more effective than single bolus101.
Tranexamic acid remains the best studied of the antifibrinolytic medications in orthopaedic surgery. Early studies demonstrated lower blood loss102, including a dose-dependent effect103. Benefit was seen when tranexamic acid was combined with cell salvage in the setting of revision total hip arthroplasty104. Meta-analyses105-107 have demonstrated less blood loss and fewer transfusions in the setting of total knee arthroplasty, with no increased thromboembolic risk. Meta-analyses of other types of arthroplasty have echoed these findings108-110.
While those studies showed promising results, caution must be taken when interpreting the meta-analysis data. The majority of studies presented short-term follow-up data, and techniques for the detection of venous thromboembolic events (deep venous thrombosis and pulmonary embolus) varied widely. The studies generally excluded high-risk patients, and, therefore, so-called proof-of-safety results may not be extrapolated to all patients. Scientific power is lacking for definitive support in high-risk patients. While tranexamic acid has shown efficacy, one may only state that it appears to be relatively safe for the majority of patients.
While the use of tranexamic acid has been associated with several minor and major side effects (e.g., nausea, diarrhea, and orthostatic reactions, with case reports of cerebral and arterial thrombosis and seizures)98,111, there are no established contraindications. Contemporary orthopaedic dosing has been far lower than historical total or loading schemes used in cardiac surgery112. Therefore, the avoidance of tranexamic acid use for certain patients—such as those with recent stents or strong history of venous thromboembolic disease—remains more practice-based at this time.
Epsilon-aminocaproic acid, another lysine analog, is six to ten times less potent than tranexamic acid and therefore is used in a different dosing regimen. Like tranexamic acid, it has a short half-life (one to two hours) and is renally excreted. At $0.56 to $1.12 per patient, epsilon-aminocaproic acid (Amicar; Xanodyne Pharmaceuticals, Newport, Kentucky) is less expensive than tranexamic acid113. This agent has shown utility in scoliosis surgery114.
Aprotinin is a serine protease inhibitor. Clinical use of this medication (Trasylol; Bayer Pharmaceuticals, Wayne, New Jersey) was suspended in 2007115 because of concern regarding an increased risk of complications. A demonstrated higher risk of cardiac death in association with the use of aprotinin versus tranexamic acid or epsilon-aminocaproic acid116 prompted withdrawal of the drug in the United States except for investigational purposes117.
Hemostatic Topical Agents
Certain collagen-based, cellulose-based, and gelatin-based agents promote platelet activation by serving as a scaffold118. Other agents, such as fibrin and thrombin products, actively generate fibrin clot and may bypass clotting steps119. Polysaccharide120 and polyethylene glycol are other topical agents with limited clinical study in arthroplasty. Bovine products should be avoided because of the potential development of antibodies (e.g., factor V) and risk of disease transmission121. First-generation animal products have been supplanted by second-generation recombinant human sources.
While reduced blood loss and transfusion rates have been shown in some studies on total knee arthroplasty and total hip arthroplasty, the benefits have been unclear in other reports122,123. The demonstrated benefits have been limited by studies involving small124 or industry-linked cohorts. With uncertain benefits, the issue of cost must be weighed carefully. A Cochrane Review suggested that fibrin products are associated with benefits in terms of blood loss but cautioned against the general lack of study blinding125.
Desmopressin, a synthetic analog of vasopressin, increases the levels of factor VIII and von Willebrand factor. It has been shown to reduce total blood loss in the setting of total hip arthroplasty126, while other studies have shown no benefit127. Recombinant factor VIIa, which enhances thrombin formation on activated platelets, is FDA-approved for the management of hemophiliac bleeding128. Its use should be reserved for unique circumstances (e.g., uncontrolled, life-threatening bleeding) in close consultation with a hematologist.
Hemostatic Surgical Tools
Hemostasis during tissue dissection and exposure is usually performed with conventional electrocautery. Other modalities include argon-beam treatment and bipolar sealing. Bipolar sealing (Aquamantys; Medtronic, Minneapolis, Minnesota) utilizes radiofrequency energy coupled with saline solution to contract collagen tissue, with several millimeters of tissue penetration. Prospective study has shown a reduction in mean total blood loss129. Barsoum et al. abandoned the use of bipolar sealing for routine primary total hip arthroplasty on the basis of the results of their randomized controlled trial130. It may be a useful adjunct for revision arthroplasty procedures associated with greater blood loss131 or for two-stage procedures in which infection precludes preoperative autologous donation or cell salvage.
Regional anesthesia, such as spinal anesthesia132, has demonstrated a benefit in terms of blood loss in patients undergoing arthroplasty133. Systematic reviews of contemporary studies of regional anesthesia (i.e., studies performed after 1990) have demonstrated a reduction in blood loss when regional anesthesia has been compared with general anesthesia in the setting of total hip arthroplasty134 but no difference in total knee arthroplasty135. Hypotensive anesthesia, while labor-intensive and usually requiring arterial line placement, has utility, especially when used in combination with regional anesthesia techniques. Sharrock et al. found that a 10-mm Hg difference in mean arterial blood pressure significantly reduced mean intraoperative blood loss in patients undergoing total hip arthroplasty (p = 0.004)136. Lieberman and Geerts reported a decreased rate of deep venous thrombosis137. Hypotensive anesthesia must be used with caution in patients with substantial cardiac or cerebrovascular issues.
Maintenance of normothermia prevents myocardial dysfunction, infection, coagulopathy138, and prolonged post-anesthetic recovery. Two studies of patients managed with total hip arthroplasty demonstrated increases in blood loss and transfusion requirements in nonwarmed as compared with actively warmed patients139,140. A meta-analysis showed benefits across multiple types of surgery, including total hip arthroplasty141.
Cell-salvage machines may provide the equivalent of ten banked blood units per hour2. The more immediately available salvaged blood may have a higher oxygen-carrying capacity and erythrocyte viability than preoperatively donated autologous blood142. In early studies, cell salvage reduced transfusion rates up to 60%143, which was borne out in a later meta-analysis144. Salvage has shown utility in the setting of revision total hip arthroplasty145, especially in patients with preoperative anemia and/or low body weight146.
Because of hemolysis, only 60% of salvaged blood is returned147. Erythrocyte viability is maintained despite processing, even when exposed to bone cementation148. Cell salvage is generally used during arthroplasty only when expected blood loss exceeds 1000 mL80 because at least two units must be recovered for the method to be clinically effective and cost-effective2. Salvage has limited utility in routine primary arthroplasty149. It cannot be used in the setting of tumor or infection150. There are limited data on the revision of metal-on-metal bearings151. Cochrane Reviews by the same authors in 2006 and 2010 demonstrated that salvage was associated with a transfusion benefit, despite the poor quality of the included trials152,153. While those reports represent recent comprehensive reviews, they may not encompass the results seen in association with more contemporary collection systems.
Tourniquet use increases fibrinolytic activity. Controversy exists with regard to the effect on blood loss. In 2011, a meta-analysis of eleven studies demonstrated that tourniquet use did not decrease calculated blood loss154. In 2010, a meta-analysis of fifteen studies demonstrated higher intraoperative blood loss without tourniquet use but showed no difference in terms of total blood loss or transfusions155. In 2012, a meta-analysis demonstrated a decrease in total and intraoperative blood loss in association with tourniquet use156.
Atraumatic dissection and meticulous hemostasis play a role. Minimizing the time that bleeding surfaces are exposed can slow blood loss, and the average blood loss is less for surgeons with higher volume and shorter operative times157. Lower blood loss has been reported in association with lateral total hip arthroplasty positioning as a result of the effects of gravity in reducing venous engorgement158. A rapid and watertight closure enhances the tamponade effect over the surgical bed159.
The use of extramedullary instrumentation for total knee arthroplasty and plugging of the canals with autologous bone or cement during total knee arthroplasty with instrumentation may be employed. Some studies have demonstrated higher transfusion rates in association with cementless total hip arthroplasty and total knee arthroplasty160. With improved understanding of component rotation and patellar tracking, the use of lateral release for total knee arthroplasty may be minimized. There is conflicting evidence to support the advantage of minimally invasive methods with regard to blood loss, and early experience with certain approaches has demonstrated more transfusions and increased operative times161. Clearly, variations in technique and other intraoperative factors may confound studies examining the effects on blood loss.
Use of Drains
Controversy exists regarding the effect of drains on blood loss. A meta-analysis of studies on total hip arthroplasty and total knee arthroplasty demonstrated greater risk of transfusion in association with drain usage (relative risk, 1.43)162. Likewise, a meta-analysis of studies on total knee arthroplasty demonstrated that closed suction drainage increased the rate of transfusion163. Pooled data from six controlled trials demonstrated no clear advantage in terms of the transfusion rate in association with drain clamping postoperatively164, although the studies did not control for the effects of intravenous volume expansion and red blood-cell dilution.
Prudent Transfusion Triggers
The evaluation of the patient undergoing total joint arthroplasty for blood transfusion must be based on the individual scenario, operative course, and comorbidities. Indeed, most postoperative clinical symptoms traditionally attributed to “anemia” are related to volume rather than to a problem with oxygen delivery. These volume deficits are often addressed appropriately with crystalloid fluid first. While intravascular volume repletion may lead to an effective hemodilution, adequate tissue oxygen extraction from circulating red blood cells may be maintained because of an unchanged red blood-cell mass. Reports in the anesthesia literature have indicated that even high-risk patients with low hemoglobin levels have preservation of metabolic function when sufficient intravascular volume is present165. Goal-directed therapy following total hip arthroplasty with the patient under regional anesthesia has demonstrated a reduction in complications without transfusion differences166.
Despite a National Institutes of Health (NIH) Consensus Statement167 in the 1980s recommending a decrease in the hemoglobin transfusion threshold from 10 to 8 g/dL for patients with no history of cardiac disease, the practice of transfusions for patients with a hemoglobin level of around 10 g/dL still continues. A restrictive transfusion threshold (hemoglobin level, 7 g/dL) has shown no difference in comparison with a liberal transfusion threshold (hemoglobin level, 10 g/dL) in terms of overall mortality in critical care patients168. More stringent criteria have been endorsed in other surgical fields169,170. The American Society of Anesthesiologists has recommended transfusion for patients with a hemoglobin level of <6 g/dL and generally not for those with a hemoglobin level of >10 g/dL171. Guidelines from the American Association of Blood Banks outline a restrictive strategy (a threshold hemoglobin level of 7 to 8 g/dL) for hospitalized, stable patients172. Cardiac disease, symptoms, or a hemoglobin level of ≤8 g/dL may prompt transfusion. Two controlled trials demonstrated no benefit in terms of the use of transfusion in association with a threshold hemoglobin level of >8 g/dL, even in patients with comorbid cardiac disease173,174.
Available since the 1980s, reinfusion drains were found to be efficacious with respect to transfusions in early175 and later176 studies. Other studies have contradicted this utility177. A meta-analysis of eight randomized studies of total knee arthroplasty showed benefits in terms of the length of stay and the transfusion rate in association with the use of reinfusion drains as compared with suction drains178. Filtration and washing reduces transfusion reactions but increases cost179. Because of cost and the quantity of blood required for processing, perhaps the best role for reinfusion drains lies in bilateral or revision arthroplasty.
Blood management in joint arthroplasty is defined by the goals of ensuring appropriate circulating volume and minimizing sources of blood loss. Avoiding allogeneic transfusion and its associated risks are a closely related aim. Careful analysis of transfusion risks must be performed preoperatively. A multimodal approach must be adopted at all time points in the surgical pathway. Blood management guidelines must be tailored to the individual patient180. Evaluation of safety is critical, especially when combining treatment modalities.
The effectiveness of many techniques remains to be proved on the basis of large-scale trials or pooled study data with sufficient power for certain conclusions or rare events. Multicenter study groups also may effect a reduction in practice variability and costs181. Broadening indications to higher-risk groups also will define safety and efficacy, including those of antifibrinolytic medications. Cost metrics must be closely considered with respect to emerging technology.
For primary total hip arthroplasty and total knee arthroplasty, and for the majority of revision procedures, one must change one’s thinking; specifically, preferential crystalloid volume support, in conjunction with modern blood conservation strategies, should precede the administration of blood cell products. This philosophy, along with a multimodal strategy including antifibrinolytic therapy, should consistently reduce the need for allogeneic transfusions.
Source of Funding: No external funding was utilized for this investigation.
Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2013 by The Journal of Bone and Joint Surgery, Incorporated