Reduction of blood transfusion rates in unilateral total knee arthroplasty by the introduction of a simple blood transfusion protocol
Introduction
Unilateral total knee arthroplasty (TKA) can result in substantial blood loss necessitating postoperative blood transfusion. Many elective surgical units use variations of the maximum surgical blood order schedule (MSBOS) [1], [2] to aid the efficiency of their blood ordering practice. However, blood ordering by this method has been shown to result in significant levels of non-utilisation of cross-matched units [3], [4], [5]. In addition, the decision to transfuse a patient postoperatively is often based on poorly defined criteria. This may, in some cases, result in inappropriate transfusion. When placed in the context of a possible health risk associated with the transmission of blood borne infective agents during allogenic blood transfusion, the reduction of unnecessary transfusion may reduce exposure of patients to potential risks.
Such a protocol depends on its ability to predict those patients at risk of transfusion. Although variants of the MSBOS [1] are commonly used, this is a basic method by which to predict transfusion requirements, as it is procedure rather than patient specific. Various patient related factors have been shown to be predictors of transfusion risk amongst surgical patients. These include total blood loss [6] type of anaesthesia [7] and the American Society of Anaesthesiologists class [7]. In total joint arthroplasty, pre operative haemoglobin has been shown to be a strong predictor of transfusion risk [6], [7], [8], [9], [10], [13], [18]. Nuttal et al. [12] showed that in patients undergoing total hip arthroplasty there was a 100% transfusion rate for patients with a pre operative haemoglobin of less than 11 g/dl.
We therefore introduced a transfusion protocol into our arthroplasty service in line with limits suggested by current Refs. [6], [7], [8], [9], [10], [12], [13], [18]. It consisted of two parts, firstly a crossmatch policy, based on the patient's pre operative haemoglobin, with the aim of ensuring that only those individuals considered at increased risk of transfusion were cross-matched preoperatively. Secondly, postoperative transfusion guidelines were adopted to ensure that patients were being transfused appropriately thereby reducing inappropriate exposure to allogenic blood transfusion amongst arthroplasty patients.
The purpose of the present study was to prospectively audit transfusion practices in patients undergoing unilateral TKA before and after the introduction of a cross matching and postoperative transfusion protocol.
Section snippets
Patients and methods
An audit nurse was employed to prospectively collect data on patients undergoing consecutive primary total knee arthroplasties between January 1995 and October 2000. The transfusion protocol was introduced in October 1998. The same 6 consultants at the same institution carried out all arthroplasties. Patients were seen 8–10 days prior to surgery in a pre assessment clinic. Their age, sex, height, weight, body mass index and American Knee Society Score were recorded (Table 1). A preoperative
Statistics
Analyses were performed using spss. Groups were compared using χ2 (with Yates correction where appropriate) for categorical data and Student t-test for continuous variables. Multiple logistic regression was used to determine the association between risk of transfusion and other variables adjusted for one another. Statistical significance was established at P<0.05.
Results
A total of 393 patients were evaluated in Group I and 295 patients in group II. The patients in these groups were comparable for age, male:female ratio, BMI, preoperative haemoglobin, and preoperative knee score as summarised in Table 1. Operative details were also similar for both groups (Table 1). Transfusion of allogenic blood was performed in 122 (31%) of the 393 patients in group I and in 35 (12%) of the 295 patients in group II. 95% confidence interval for the difference in transfusion
Discussion
The blood loss during unilateral TKA has been shown in a number of studies to be considerable. Mean haemoglobin drops of between 0.7 and 3.85 g/dl [6], [14] have been documented. As a result the extent of postoperative transfusion is not insignificant with rates of 12.5% [11] to 64% [15] being reported in the literature. Allogenic blood transfusion has potential adverse events. These range from the mild febrile allergic reactions to severe haemolytic reactions as a result of transfusion errors
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