title: Patient blood management in elective total hip- and knee-replacement surgery (part 2): a randomized controlled trial on blood salvage as transfusion alternative using a restrictive transfusion policy in patients with a preoperative hemoglobin above 13 g/dl.
abstract: BACKGROUND
  Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion.
  
  
  METHODS
  Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness.
  
  
  RESULTS
  In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by €298 per patient (95% CI, 76 to 520).
  
  
  CONCLUSIONS
  In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.
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 (LUMC), 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, 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, LUMC, Leiden, The Netherlands (T.M.J.-W. and R.B.); Department of Medical Decision Making, LUMC, Leiden, The Netherlands (W.B.v.d.H.); and Department of Immunohaematology and Blood Transfusion Service, LUMC, 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*; D001803:Blood Transfusion / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; 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; D006454:Hemoglobins / Q000032:analysis*; D006801:Humans; D008297:Male; D009426:Netherlands; 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: D006454:Hemoglobins; D004921:Erythropoietin