title: National comparative audit of blood use in elective primary unilateral total hip replacement surgery in the UK.
abstract: BACKGROUND
  Blood is a scarce and expensive product. Although it may be life-saving, in recent years there has been an increased emphasis on the potential hazards of transfusion as well as evidence supporting the use of lower transfusion thresholds. Orthopaedic surgery accounts for some 10% of transfused red blood cells and evidence suggests that there is considerable variation in transfusion practice.
  
  
  METHODS
  NHS Blood and Transplant, in collaboration with the Royal College of Physicians, undertook a national audit on transfusion practice. Each hospital was asked to provide information relating to 40 consecutive patients undergoing elective, primary unilateral total hip replacement surgery. The results were compared to indicators and standards.
  
  
  RESULTS
  Information was analysed relating to 7465 operations performed in 223 hospitals. Almost all hospitals had a system for referring abnormal pre-operative blood results to a doctor and 73% performed a group-and-save rather than a cross-match before surgery. Of hospitals, 47% had a transfusion policy. In 73%, the policy recommended a transfusion threshold at a haemoglobin concentration of 8 g/dl or less. There was a wide variation in transfusion rate among hospitals. Of patients, 15% had a haemoglobin concentration less than 12 g/dl recorded in the 28 days before surgery and 57% of these patients were transfused compared to 20% with higher pre-operative values. Of those who were transfused, 7% were given a single unit and 67% two units. Of patients transfused two or more units during days 1-14 after surgery, 65% had a post transfusion haemoglobin concentration of 10 g/dl or more.
  
  
  CONCLUSIONS
  Pre-operative anaemia, lack of availability of transfusion protocols and use of different thresholds for transfusion may have contributed to the wide variation in transfusion rate. Effective measures to identify and correct pre-operative anaemia may decrease the need for transfusion. A consistent, evidence-based, transfusion threshold should be used and transfusion of more than one unit should only be given if essential to maintain haemoglobin concentrations above this threshold.
authors.affiliation: Department of Transfusion Medicine, National Health Service Blood & Transplant, Brentwood, Essex, UK. hari.boralessa@nhsbt.nhs.uk
authors.forename: H
authors.initials: H
authors.lastname: Boralessa
authors.forename: D R
authors.initials: DR
authors.lastname: Goldhill
authors.forename: K
authors.initials: K
authors.lastname: Tucker
authors.forename: A J
authors.initials: AJ
authors.lastname: Mortimer
authors.forename: J
authors.initials: J
authors.lastname: Grant-Casey
mesh_terms: D019644:Arthroplasty, Replacement, Hip / Q000592:standards*; D001803:Blood Transfusion / Q000592:standards / Q000706:statistics & numerical data*; D017558:Elective Surgical Procedures / Q000592:standards / Q000706:statistics & numerical data; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D008485:Medical Audit; D019990:Perioperative Care; D011184:Postoperative Period; D011300:Preoperative Care; D057234:Preoperative Period; D013222:State Medicine; D006113:United Kingdom
chemical_list: D006454:Hemoglobins
references.citation: Anesth Analg. 2005 Dec;101(6):1858-1861
references.pmid: 16301274
references.citation: J Bone Joint Surg Am. 2004 Jul;86(7):1512-8
references.pmid: 15252101
references.citation: Vox Sang. 2002 Nov;83(4):352-7
references.pmid: 12437523
references.citation: Transfusion. 2007 May;47(5):832-41
references.pmid: 17465948
references.citation: Transfusion. 2003 Dec;43(12):1717-22
references.pmid: 14641869
references.citation: J Bone Joint Surg Br. 2004 Sep;86(7):970-3
references.pmid: 15446520
references.citation: Transfus Med. 2005 Aug;15(4):307-12
references.pmid: 16101808
references.citation: Anesth Analg. 1970 Jul-Aug;49(4):564-6
references.pmid: 5534668
references.citation: BMJ. 2004 Apr 17;328(7445):934-8
references.pmid: 15087341
references.citation: Anesth Analg. 1997 Apr;84(4):839-44
references.pmid: 9085968
references.citation: N Engl J Med. 1999 Feb 11;340(6):409-17
references.pmid: 9971864
references.citation: Orthopedics. 2005 May;28(5):453-8
references.pmid: 15945601
references.citation: Anesth Analg. 2005 May;100(5):1416-1421
references.pmid: 15845698
references.citation: Transfus Med. 1998 Dec;8(4):309-17
references.pmid: 9881425
references.citation: Lancet. 1996 Oct 19;348(9034):1055-60
references.pmid: 8874456
references.citation: Eur J Anaesthesiol. 2002 Nov;19(11):829-31
references.pmid: 12442934
references.citation: Vox Sang. 2006 Feb;90(2):105-12
references.pmid: 16430668
references.citation: Ann Intern Med. 2000 Dec 5;133(11):845-54
references.pmid: 11103054
references.citation: J Orthop Trauma. 2004 Jul;18(6):369-74
references.pmid: 15213502
references.citation: Transfusion. 2007 Aug;47(8):1468-80
references.pmid: 17655591
references.citation: JAMA. 1998 Jan 21;279(3):199-205
references.pmid: 9438739
references.citation: Br J Anaesth. 2007 Dec;99(6):794-800
references.pmid: 17928302
references.citation: J Trauma. 2003 May;54(5):908-14
references.pmid: 12777903
references.citation: J Am Acad Orthop Surg. 2002 Nov-Dec;10(6):393-400
references.pmid: 12470041
references.citation: Int Orthop. 2008 Jun;32(3):325-9
references.pmid: 17396259
references.citation: BMJ. 2002 Oct 12;325(7368):803
references.pmid: 12376439
references.citation: Lancet. 1996 Feb 3;347(8997):289-92
references.pmid: 8569362
references.citation: J Bone Joint Surg Br. 2003 May;85(4):484-9
references.pmid: 12793549
references.citation: Br J Anaesth. 2007 Dec;99(6):801-8
references.pmid: 17959586
references.citation: Eur J Anaesthesiol. 2003 Dec;20(12):963-6
references.pmid: 14690098
references.citation: Eur J Anaesthesiol. 2005 Apr;22(4):249-57
references.pmid: 15892401
references.citation: Br J Haematol. 2001 Apr;113(1):24-31
references.pmid: 11328275
references.citation: Crit Care Med. 2002 Oct;30(10):2249-54
references.pmid: 12394952
references.citation: Anesth Analg. 2000 Oct;91(4):978-84
references.pmid: 11004060
references.citation: Acta Orthop Scand. 2003 Oct;74(5):569-75
references.pmid: 14620978
references.citation: Can J Anaesth. 2003 Jun-Jul;50(6 Suppl):S60-4
references.pmid: 14629055
references.citation: Transfusion. 2003 Apr;43(4):459-69
references.pmid: 12662278
references.citation: BMJ. 1999 Jul 3;319(7201):16-9
references.pmid: 10390452
references.citation: Crit Care Med. 2003 Dec;31(12 Suppl):S678-86
references.pmid: 14724466