title: Patient blood management in elective total hip- and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients.
abstract: BACKGROUND
  Patient blood management combines the use of several transfusion alternatives. Integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices on allogeneic erythrocyte use was evaluated using a restrictive transfusion threshold.
  
  
  METHODS
  In a factorial design, adult elective hip- and knee-surgery patients with hemoglobin levels 10 to 13 g/dl (n = 683) were randomized for erythropoietin or not, and subsequently for autologous reinfusion by cell saver or postoperative drain reinfusion devices or for no blood salvage device. Primary outcomes were mean allogeneic intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness.
  
  
  RESULTS
  With erythropoietin (n = 339), mean erythrocyte use was 0.50 units (U)/patient and transfusion rate 16% while without (n = 344), these were 0.71 U/patient and 26%, respectively. Consequently, erythropoietin resulted in a nonsignificant 29% mean erythrocyte reduction (ratio, 0.71; 95% CI, 0.42 to 1.13) and 50% reduction of transfused patients (odds ratio, 0.5; 95% CI, 0.35 to 0.75). Erythropoietin increased costs by €785 per patient (95% CI, 262 to 1,309), that is, €7,300 per avoided transfusion (95% CI, 1,900 to 24,000). With autologous reinfusion, mean erythrocyte use was 0.65 U/patient and transfusion rate was 19% with erythropoietin (n = 214) and 0.76 U/patient and 29% without (n = 206). Compared with controls, autologous blood reinfusion did not result in erythrocyte reduction and increased costs by €537 per patient (95% CI, 45 to 1,030).
  
  
  CONCLUSIONS
  In hip- and knee-replacement patients (hemoglobin level, 10 to 13 g/dl), even with a restrictive transfusion trigger, erythropoietin significantly avoids transfusion, however, at unacceptably high costs. Autologous blood salvage devices were not effective.
authors.affiliation: From the Department Center of Clinical Transfusion Research, Sanquin Blood Supply, Leiden, The Netherlands (C.S.-O., J.A.V.H., and A.B.); Department of Orthopedic Surgery, Leiden University Medical Center, RC Leiden, The Netherlands (R.G.H.H.N.); Department of Anaesthesiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands (A.W.M.M.K.-v.G.); Department of Anaesthesiology, Slotervaart Hospital, Amsterdam, The Netherlands (E.K.); Department of Orthopedic Surgery, Slotervaart Hospital, Amsterdam, The Netherlands, and VU University Medical Center, Amsterdam, The Netherlands (R.G.P.); Department of Orthopedic Surgery, Groene Hart Hospital, Gouda, The Netherlands (R.O.); Department of Medical Statistics and BioInformatics, Leiden University Medical Center, Leiden, The Netherlands (T.M.J.-W. and R.B.); Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands (W.B.v.d.H.); and Department of Immunohaematology and Blood Transfusion Service, Leiden University Medical Center, Leiden, The Netherlands (A.B.).
authors.forename: Cynthia
authors.initials: C
authors.lastname: So-Osman
authors.forename: Rob G H H
authors.initials: RG
authors.lastname: Nelissen
authors.forename: Ankie W M M
authors.initials: AW
authors.lastname: Koopman-van Gemert
authors.forename: Ewoud
authors.initials: E
authors.lastname: Kluyver
authors.forename: Ruud G
authors.initials: RG
authors.lastname: Pöll
authors.forename: Ron
authors.initials: R
authors.lastname: Onstenk
authors.forename: Joost A
authors.initials: JA
authors.lastname: Van Hilten
authors.forename: Thekla M
authors.initials: TM
authors.lastname: Jansen-Werkhoven
authors.forename: Wilbert B
authors.initials: WB
authors.lastname: van den Hout
authors.forename: Ronald
authors.initials: R
authors.lastname: Brand
authors.forename: Anneke
authors.initials: A
authors.lastname: Brand
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000379:methods*; D001804:Blood Transfusion, Autologous / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D003362:Cost-Benefit Analysis; D004311:Double-Blind Method; D004322:Drainage / Q000191:economics / Q000295:instrumentation / Q000379:methods; D017558:Elective Surgical Procedures / Q000379:methods*; D004921:Erythropoietin / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D009426:Netherlands; D016017:Odds Ratio; D057725:Operative Blood Salvage / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D011182:Postoperative Care / Q000191:economics / Q000295:instrumentation / Q000379:methods; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D004921:Erythropoietin