An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery.
In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects--e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.
Slappendel
Robert
R
Department of Anaesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands. r.slappendel@maartenskliniek.nl
Dirksen
Ris
R
Weber
Eric W G
EW
van der Schaaf
Dick B
DB
D000465:Algorithms; D007611:Aprotinin / Q000627:therapeutic use; D019644:Arthroplasty, Replacement, Hip; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001803:Blood Transfusion; D002985:Clinical Protocols; D006490:Hemostatics / Q000627:therapeutic use; D006801:Humans; D019637:Orthopedic Procedures
D006490:Hemostatics; D007611:Aprotinin