JBJS | Efficacy of Postoperative Blood Salvage Following Total Hip Arthroplasty in Patients with and without Deposited Autologous Units*

The Journal of Bone & Joint Surgery, Volume 82, Issue 7

Articles | July 01, 2000

Efficacy of Postoperative Blood Salvage Following Total Hip Arthroplasty in Patients with and without Deposited Autologous Units*

David Grosvenor, M.P.H.†; Varish Goyal, B.S.†; Stuart Goodman, M.D., Ph.D†

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Investigation performed at the Division of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Division of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Drive, Room R-144, Stanford, California 94305. E-mail address for S. Goodman: goodbone@leland.stanford.edu.

The Journal of Bone & Joint Surgery. 2000; 82:951-951

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Abstract

Background: Patients undergoing total hip replacement routinely receive perioperative blood transfusions, increasing their risk of blood-borne disease, isoimmunization, anaphylactic reaction, and hemolytic reaction. The purpose of this retrospective, case-control study was to evaluate the effect of postoperative blood salvage on the need for allogeneic transfusion following total hip replacement.

Methods: We reviewed the medical records of ninety consecutive patients who, during a twelve-month period, had undergone unilateral, elective total hip replacement that included use of a postoperative blood salvage device. For comparison, we reviewed the medical records of ninety consecutive patients who had undergone total hip replacement without postoperative blood salvage. Overall, 156 patients had complete medical records and were included in the study.

Results: Eight (10 percent) of the patients who had been treated with a drain and seventeen (23 percent) of the patients who had been treated without a drain received allogeneic transfusions. Of the nineteen patients who had not deposited autologous blood, all six without postoperative blood salvage required allogeneic transfusion. With control for other variables in the model, regression analysis showed a significantly increased risk of allogeneic transfusion among patients who had undergone total hip replacement without postoperative blood salvage (p = 0.0028) and without having predonated autologous units (p = 0.0001).

Conclusions: Despite a limited sample size, the study results showed that postoperative blood salvage significantly reduced the risk of allogeneic transfusion among patients managed with total hip replacement, whether or not they had deposited autologous blood (p < 0.0001). With control for donated units, age, gender, preoperative hematocrit, intraoperative blood loss, and cementless technique, patients who were treated without postoperative blood salvage were approximately ten times more likely to require allogeneic transfusion than were patients who had a drain.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Patients managed with total hip replacement routinely receive blood transfusions in order to replace blood that is lost intraoperatively and postoperatively. Cementless prostheses have been associated with greater blood loss than cemented prostheses and therefore have often been associated with greater blood requirements⁵. Transfusion of allogeneic blood introduces several risk factors, including blood-borne disease, isoimmunization, anaphylactic reaction, and hemolytic reaction. Viral diseases that may be transmitted through allogeneic transfusion include human immunodeficiency virus, hepatitis, cytomegalovirus, and human T-cell lymphotrophic virus.

Several methods have been found to be successful in reducing the need for allogeneic transfusion among patients undergoing total hip replacement. Preoperative deposition of autologous blood, intraoperative blood salvage, and postoperative blood salvage have decreased the use of allogeneic blood^2,7,8. The effects of postoperative blood salvage on the need for allogeneic transfusion have varied according to the availability of deposited blood and the use of intraoperative blood salvage. Ayers et al. found postoperative blood salvage to be effective in reducing the need for allogeneic transfusion in patients for whom deposited autologous units were unavailable¹. However, they found that postoperative blood salvage had no effect on the prevalence of allogeneic transfusion among patients who had deposited units. In a comparison of the effects of preoperative autologous donation, intraoperative blood salvage (such as with the Cell Saver device [Haemonetics, Braintree, Massachusetts]), and postoperative blood salvage, Huo et al. found that the need for allogeneic transfusion was reduced the most in patients who had deposited autologous units and had also had intraoperative blood salvage⁶. The addition of postoperative blood salvage did not substantially reduce the chance of allogeneic transfusion.

The purpose of this retrospective, case-control study was to evaluate the effect of postoperative blood salvage on the need for allogeneic transfusion among patients managed with total hip replacement without intraoperative blood salvage. Because most patients undergoing elective total hip replacement at our institution deposit two units of autologous blood, we were particularly interested in whether postoperative blood salvage offered any added benefit.

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Fig. 1:: Graph showing the likelihood of allogeneic transfusion in a sixty-year-old man with one unit of deposited autologous blood, a preoperative hematocrit of 0.35, and a cementless prosthesis.

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Table I: Allogeneic Transfusion and Postoperative Blood Salvage*

*Sixteen percent of the patients in the study, 10 percent of those with postoperative blood salvage, and 23 percent of those without postoperative blood salvage had a transfusion with allogeneic units.

	Postoperative Blood Salvage
No	Yes	Total
No. of patients receiving allogeneic transfusion
Yes	17	8	25 (16%)
No	57	74	131 (84%)
Total	74	82	156
Rate of allogeneic transfusion	23%	10%

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Table I: Allogeneic Transfusion and Postoperative Blood Salvage*

	Postoperative Blood Salvage
No	Yes	Total
No. of patients receiving allogeneic transfusion
Yes	17	8	25 (16%)
No	57	74	131 (84%)
Total	74	82	156
Rate of allogeneic transfusion	23%	10%

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Table II: Logistic Regression Analysis with Allogeneic Transfusion as the Dependent Variable

*Odds ratio of each variable, controlling for other variables in the model.

Variable	Beta Coefficient, or Slope	Standard Error of Beta Coefficient	Level of Significance	Estimated Odds Ratio*	95 Percent Confidence Limits of Estimated Odds Ratio
Lower	Upper
Cement fixation	-0.0824	0.8107	0.9191	0.9209	0.1880	4.5114
Age	0.0252	0.0256	0.3255	1.0255	0.9753	1.0782
Gender	0.2234	0.7177	0.7556	1.2503	0.3063	5.1035
Preop. hematocrit	-0.1498	0.0888	0.0917	0.8609	0.7233	1.0246
Blood loss			0.4203
Â£300 ml	-0.9970	0.7959	0.2103	0.3690	0.0775	1.7559
301-600 ml	-0.3272	0.7166	0.6479	0.7209	0.1770	2.9365
Postop. blood salvage	2.4455	0.8172	0.0028	11.5363	2.3253	57.2331
Predonated blood			0.0000
No units	4.4259	0.9749	0.0000	83.5845	12.3672	564.9101
1 unit	2.0820	0.9830	0.0342	8.0207	1.1680	55.0787
Constant	0.1196	3.8671	0.9753

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Table II: Logistic Regression Analysis with Allogeneic Transfusion as the Dependent Variable

*Odds ratio of each variable, controlling for other variables in the model.

Variable	Beta Coefficient, or Slope	Standard Error of Beta Coefficient	Level of Significance	Estimated Odds Ratio*	95 Percent Confidence Limits of Estimated Odds Ratio
Lower	Upper
Cement fixation	-0.0824	0.8107	0.9191	0.9209	0.1880	4.5114
Age	0.0252	0.0256	0.3255	1.0255	0.9753	1.0782
Gender	0.2234	0.7177	0.7556	1.2503	0.3063	5.1035
Preop. hematocrit	-0.1498	0.0888	0.0917	0.8609	0.7233	1.0246
Blood loss			0.4203
Â£300 ml	-0.9970	0.7959	0.2103	0.3690	0.0775	1.7559
301-600 ml	-0.3272	0.7166	0.6479	0.7209	0.1770	2.9365
Postop. blood salvage	2.4455	0.8172	0.0028	11.5363	2.3253	57.2331
Predonated blood			0.0000
No units	4.4259	0.9749	0.0000	83.5845	12.3672	564.9101
1 unit	2.0820	0.9830	0.0342	8.0207	1.1680	55.0787
Constant	0.1196	3.8671	0.9753

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

An independent chart auditor, supervised by an epidemiologist, reviewed the medical records of ninety consecutive patients who had been more than thirty years old when they underwent a unilateral, elective total hip replacement that included use of a CBC ConstaVac drain (Stryker, Kalamazoo, Michigan); the patients were treated during a twelve-month period (October 1997 to October 1998). For comparison, we reviewed the medical records of ninety consecutive patients who had undergone total hip replacement without postoperative blood salvage during the same twelve-month period. The use of postoperative blood salvage was determined by the preference of the individual surgeon. Ten surgeons participated in the study. Patients were excluded a priori if they had undergone a revision operation or a bilateral total hip replacement (three patients) or if they had had intraoperative blood salvage (thirteen patients). Blood collection took place in the initial six hours following the total hip replacement; the collection was carried out on a patient ward by a ward nurse. If less than 100 milliliters of salvaged blood was collected by the device within the six-hour time-period, reinfusion did not occur and the salvaged blood was discarded. Autologous and allogeneic units were transfused on the basis of a variety of criteria, including clinical symptoms such as dizziness; a hematocrit of less than 0.30; and a history of angina, myocardial infarction, tachycardia, or postural hypotension. The decision to perform a transfusion was made by each surgeon and patient without a formal protocol.

Statistical Analysis

Univariate analyses were used to assess patient demographics and diagnoses. In order to assess comparability between the groups and to analyze average volumes of blood loss and reinfusion, independent t tests were conducted on a series of variables. Odds ratios for allogeneic transfusion were used to measure associations between postoperative blood salvage and allogeneic transfusion. Backward elimination logistic regression was used to measure associations between postoperative blood salvage and allogeneic transfusion while controlling for perioperative factors such as age, gender, preoperative hematocrit, deposited autologous units, intraoperative blood loss, and whether a cementless technique had been used to fix the prosthesis. In the multivariate analyses, allogeneic transfusion and postoperative blood salvage were treated as dichotomous variables. The preoperative hematocrit and the blood-reinfusion volumes were treated as continuous variables. Because of the non-normal distribution of blood-loss values, intraoperative blood loss was treated as a three-level variable (300 milliliters or less, 301 to 600 milliliters, and more than 600 milliliters).

Results

Introduction | Materials and Methods | Results | Discussion | References

Twenty-four patients had incomplete medical records and were excluded from the study. The study thus consisted of 156 patients, sixty-three (40 percent) of whom were male and ninety-three (60 percent) of whom were female. The average age (and standard deviation) was 63.9 ±13.34 years (range, 29.0 to 94.0 years).

Eighty-two consecutive patients underwent operations with postoperative blood salvage (Group A). The implants in this group consisted of seventy-four cementless and eight hybrid prostheses. There were fifty-one women and thirty-one men in Group A, and their average age at the time of the index procedure was sixty-two years (95 percent confidence interval, 59.0 to 65.0 years). Seventy-four consecutive patients underwent total hip replacement without postoperative blood salvage (Group B). The implants used in this group consisted of fifty-seven cementless and seventeen hybrid prostheses. There were forty-two women and thirty-two men in Group B, and their average age at the time of the index procedure was sixty-six years (95 percent confidence interval, 63.2 to 68.9 years).

The preoperative hematocrit and the intraoperative and postoperative blood loss did not differ significantly between Groups A and B (p > 0.05). An average of 264 199 milliliters of postoperatively salvaged blood was reinfused in Group A. Twenty patients had less than fifty milliliters of postoperative blood loss and did not have reinfusion. When this subset was excluded, the average amount of reinfused salvaged blood was 349 ±149 milliliters. The total volume of blood loss (intraoperative and postoperative loss minus the volume of reinfused salvaged blood) was significantly lower in Group A than in Group B (p = 0.002, two-tailed level of significance [t test for equality of means]), with a mean difference of 153 milliliters (95 percent confidence interval, 67.5 to 283.2 milliliters). The total blood volume that was reinfused was significantly higher in Group A than in Group B (p = 0.0001, two-tailed level of significance [t test for equality of means]), with a mean difference of 265 milliliters (95 percent confidence interval, 134.2 to 396.6 milliliters).

Eight patients (10 percent) in Group A and seventeen patients (23 percent) in Group B received allogeneic transfusions (Table I). Analysis performed without controlling for other perioperative factors showed that patients without postoperative blood salvage were almost three times more likely to require allogeneic transfusion than patients with postoperative blood salvage (odds ratio, 2.76; 95 percent confidence interval, 1.11 to 6.51; p < 0.05). The odds of allogeneic transfusion differed according to the availability of deposited autologous blood. In the group of nineteen patients who had not deposited autologous blood, all six without postoperative blood salvage required allogeneic transfusion and six of the thirteen with postoperative blood salvage required allogeneic transfusion. Because all six of the patients who had not deposited blood and who had not had postoperative blood salvage received allogeneic transfusions, odds ratios could not be calculated.

Results of Multivariate Analysis

Use of postoperative blood salvage and the amount of deposited autologous blood were significantly associated with allogeneic blood transfusion (p = 0.0001). Backward elimination logistic regression showed a significantly increased risk of allogeneic transfusion among patients who had undergone total hip replacement without postoperative blood salvage (p = 0.0028) and without having predonated autologous units (p = 0.0001). Patients who had donated one unit were at higher risk than patients who had donated two units (p = 0.0342), but they were at lower risk than patients who had no autologous blood available (p = 0.0001). Analysis performed with control for donated units, age, gender, preoperative hematocrit, intraoperative blood loss, and cementless technique (Table II) showed that patients without postoperative blood salvage were approximately ten times more likely to require allogeneic transfusion than patients who had been managed with the drain. No other main effects or interactions were significantly associated with allogeneic transfusion (p > 0.05).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Complications associated with allogeneic transfusion have led orthopaedic surgeons to develop practices to maximize use of the patient's own blood during operations. Depositing units of autologous blood before operations resulted in the most substantial reductions in allogeneic transfusions in our study and others^2,6. While the Cell Saver intraoperative blood salvage system has also proved effective, issues related to cost have raised questions concerning its use. Postoperative blood salvage after total hip replacement has been in widespread use and has proved to be safe and effective⁴. The results of our study showed postoperative blood salvage to significantly reduce the risk of allogeneic transfusion after total hip replacement in patients who had deposited autologous blood and in those who had not (p < 0.0001). The prevalence of allogeneic transfusion was highest in patients who had not deposited units; twelve of nineteen such patients received allogeneic transfusions. Thirteen of the nineteen patients had the reinfusion drain, and six did not. Six of the thirteen patients with the reinfusion drain received allogeneic blood, and all six patients with neither the reinfusion drain nor deposited units required allogeneic blood. Additionally, patients with postoperative blood salvage had significantly lower perioperative blood loss (p = 0.002).

It has been previously reported that postoperative blood salvage does not substantially reduce the risk of allogeneic transfusion in patients who have deposited blood¹. Our analysis, which controlled for several perioperative factors, including the availability of autologous blood, demonstrated a substantially lower risk of allogeneic transfusion among patients with postoperative blood salvage. For example, a sixty-year-old male patient with one unit of deposited autologous blood, a preoperative hematocrit of 0.35, and intraoperative blood loss of 300 milliliters or less who undergoes a cementless procedure with postoperative blood salvage has a 1 percent probability of allogeneic transfusion (Fig. 1). The probability of allogeneic transfusion for a patient without postoperative blood salvage, but with the same perioperative characteristics, is 12 percent. If the described patient has an intraoperative blood loss of 301 to 600 milliliters, he has a 2 percent probability of allogeneic transfusion if postoperative drainage is used and a 21 percent probability if postoperative drainage is not used.

In addition to reducing the risk of complications that are associated with allogeneic transfusion, postoperative blood salvage may offer other benefits, including reducing the amount of blood that needs to be donated preoperatively. Graham et al. reported that patients who had donated blood preoperatively were positive about the experience and did not report more symptoms than patients who had not donated blood preoperatively³. However, the former group underestimated their risk of allogeneic transfusion. The effectiveness of postoperative blood salvage in preventing allogeneic transfusion among patients who have donated blood may add an element of patient satisfaction to total hip replacement. Given the low cost of postoperative blood salvage and the potentially substantial benefits for the patient, we recommend its use after total hip replacement regardless of the availability of donated autologous units.

Our study group comprised 156 patients who had undergone total hip replacement with or without a reinfusion device. This limited postoperative study is comparable in sample size with others^1,6-8; however, a larger study may further define other variables that are important with regard to the risk of allogeneic blood transfusion, especially in patients who have not deposited blood.

References

Introduction | Materials and Methods | Results | Discussion | References

Ayers, D. C.; Murray, D. G.; and Duerr, D. M.: Blood salvage after total hip arthroplasty. J. Bone and Joint Surg.,77-A: 1347-1351, Sept. 1995.77-A1347 1995

Bierbaum, B. E.; Callaghan, J. J.; Galante, J. O.; Rubash, H. E.; Tooms, R. E.; and Welch, R. B.: An analysis of blood management in patients having a total hip or knee arthroplasty. J. Bone and Joint Surg.,81-A: 2-10, Jan 1999.81-A2 1999

Graham, I. D.; Fergusson, D.; Dokainish, H.; Biggs, J.; McAuley, L.; and Laupacis, A.: Autologous versus allogeneic transfusion: patients' perceptions and experiences. CMAJ: Canadian Med. Assn. J.,160: 989-995, 1999.160989 1999

Han, C. D., and Shin, D. E.: Postoperative blood salvage and reinfusion after total joint arthroplasty. J. Arthroplasty,12: 511-516, 1997.12511 1997 [PubMed]

Hays, M. B., and Mayfield, J. F.: Total blood loss in major joint arthroplasty. A comparison of cemented and noncemented hip and knee operations. J. Arthroplasty,3 (Supplement): 47-S49, 1988.3 (Supplement)47 1988

Huo, M. H.; Paly, W. P.; and Kreggi, K. J.: Effect of preoperative autologous blood donation and intraoperative and postoperative blood recovery on homologous blood transfusion requirement in cementless total hip replacement operation. J. Am. Coll. Surgeons,180: 561-567, 1995.180561 1995

Thomson, J. D.; Callaghan, J. J.; Savory, C. G.; Stanton, R. P.; and Pierce, R. N.: Prior deposition of autologous blood in elective orthopaedic surgery. J. Bone and Joint Surg.,69-A: 320-324, March 1987.69-A320 1987

Woolson, S. T.; Marsh, J. S.; and Tanner, J. B.: Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery. J. Bone and Joint Surg.,69-A: 325-328, March 1987.69-A325 1987

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Fig. 1:: Graph showing the likelihood of allogeneic transfusion in a sixty-year-old man with one unit of deposited autologous blood, a preoperative hematocrit of 0.35, and a cementless prosthesis.

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Table I: Allogeneic Transfusion and Postoperative Blood Salvage*

	Postoperative Blood Salvage
No	Yes	Total
No. of patients receiving allogeneic transfusion
Yes	17	8	25 (16%)
No	57	74	131 (84%)
Total	74	82	156
Rate of allogeneic transfusion	23%	10%

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Table I: Allogeneic Transfusion and Postoperative Blood Salvage*

	Postoperative Blood Salvage
No	Yes	Total
No. of patients receiving allogeneic transfusion
Yes	17	8	25 (16%)
No	57	74	131 (84%)
Total	74	82	156
Rate of allogeneic transfusion	23%	10%

View Larger

Table II: Logistic Regression Analysis with Allogeneic Transfusion as the Dependent Variable

*Odds ratio of each variable, controlling for other variables in the model.

Variable	Beta Coefficient, or Slope	Standard Error of Beta Coefficient	Level of Significance	Estimated Odds Ratio*	95 Percent Confidence Limits of Estimated Odds Ratio
Lower	Upper
Cement fixation	-0.0824	0.8107	0.9191	0.9209	0.1880	4.5114
Age	0.0252	0.0256	0.3255	1.0255	0.9753	1.0782
Gender	0.2234	0.7177	0.7556	1.2503	0.3063	5.1035
Preop. hematocrit	-0.1498	0.0888	0.0917	0.8609	0.7233	1.0246
Blood loss			0.4203
Â£300 ml	-0.9970	0.7959	0.2103	0.3690	0.0775	1.7559
301-600 ml	-0.3272	0.7166	0.6479	0.7209	0.1770	2.9365
Postop. blood salvage	2.4455	0.8172	0.0028	11.5363	2.3253	57.2331
Predonated blood			0.0000
No units	4.4259	0.9749	0.0000	83.5845	12.3672	564.9101
1 unit	2.0820	0.9830	0.0342	8.0207	1.1680	55.0787
Constant	0.1196	3.8671	0.9753

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Table II: Logistic Regression Analysis with Allogeneic Transfusion as the Dependent Variable

*Odds ratio of each variable, controlling for other variables in the model.

Variable	Beta Coefficient, or Slope	Standard Error of Beta Coefficient	Level of Significance	Estimated Odds Ratio*	95 Percent Confidence Limits of Estimated Odds Ratio
Lower	Upper
Cement fixation	-0.0824	0.8107	0.9191	0.9209	0.1880	4.5114
Age	0.0252	0.0256	0.3255	1.0255	0.9753	1.0782
Gender	0.2234	0.7177	0.7556	1.2503	0.3063	5.1035
Preop. hematocrit	-0.1498	0.0888	0.0917	0.8609	0.7233	1.0246
Blood loss			0.4203
Â£300 ml	-0.9970	0.7959	0.2103	0.3690	0.0775	1.7559
301-600 ml	-0.3272	0.7166	0.6479	0.7209	0.1770	2.9365
Postop. blood salvage	2.4455	0.8172	0.0028	11.5363	2.3253	57.2331
Predonated blood			0.0000
No units	4.4259	0.9749	0.0000	83.5845	12.3672	564.9101
1 unit	2.0820	0.9830	0.0342	8.0207	1.1680	55.0787
Constant	0.1196	3.8671	0.9753

Ayers, D. C.; Murray, D. G.; and Duerr, D. M.: Blood salvage after total hip arthroplasty. J. Bone and Joint Surg.,77-A: 1347-1351, Sept. 1995.77-A1347 1995

Han, C. D., and Shin, D. E.: Postoperative blood salvage and reinfusion after total joint arthroplasty. J. Arthroplasty,12: 511-516, 1997.12511 1997 [PubMed]

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David Grosvenor, Varish Goyal, Stuart Goodman; Efficacy of Postoperative Blood Salvage Following Total Hip Arthroplasty in Patients with and without Deposited Autologous Units*. The Journal of Bone & Joint Surgery. 2000 Jul;82(7):951-951.

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