Utilization and effectiveness of autologous blood donation for arthroplastic surgery

Utilization and Effectiveness of Autologous Blood Donation for Arthroplastic Surgery

L. T. G o o d n o u g h ,

M D , D. S h a f r o n , a n d R. E. M a r c u s

Abstract: Autologous blood predeposit before elective surgery is a rapidly expanding transfusion practice. The authors have conducted a 3-year analysis of an autologous blood predeposit program to assess its impact on orthopaedic joint surgery. The authors conclude: autologous blood donation has resulted in a reduction of homologous blood transfusions in patients undergoing elective hip and knee procedures from 73% to 18% and from 71% to 12%, respectively. In addition, autologous blood preoperative donation in elective orthopaedic joint surgery has increased dramatically, so that while previously this practice was considered undemtilized, atttologous blood as an alternative to homologous blood transfusion now represents a standard of practice for elective orthopaedic joint arthroplasty at University Hospitals of Cleveland. Key words: autologous blood, arthroplasty, blood transfusion.

Autologous blood predeposit is a widely endorsed transfusion practice that has been increasingly applied in elective transfusion settings (2, 4, 9, 21, 23, 25, 30). Recent studies have indicated that despite the support for this practice, autologous blood programs are underutilized (21, 30). Autologous blood represents approximately 2% of the blood transfused annually in the United States (3); estimates of the potential contribution of autologous blood units to blood inventory, if all patients eligible to predeposit autologous blood did so, range from 1 0 - 1 4 % (21, 30). Orthopaedic surgical patients undergoing joint surgery are particularly appropriate candidates for autologous blood predeposit. These procedures are elective and c o m m o n l y require blood replacement; thus, orthopaedic patients comprise one of the largFrom the Case Western Reserve University School of Medicine, Cleveland, Ohio.

L. T. Goodnough is a recipient of a Transfusion Medicine Academic Award from the National Heart, Lung, Blood, Institute (K07-11L01625). Reprint requests: LawrenceTim Goodnough, MD, Department of Medicine, University ttospitals of Cleveland, 2074 Abington Road, Cleveland, OH 44106.

est group of patients w h o participate in autologous blood programs (2 I, 30, 32). To assess the impact of autologous blood preoperative donation o n orthopaedic joint arthroplasty, we have conducted a retrospective 3-year analysis of the utilization and effectiveness of autologous blood predeposit in adult orthopaedic patients undergoing elective joint surgery.

Materials and Methods Audit Orthopaedic surgery .blood bank records and patient charts were reviewed for the period 7 / I / 8 5 - 6 / 30/88. Seven hundred nineteen adult patients scheduled for elective orthopaedic joint procedures, for w h o m blood type and crossmatch were requested, were considered eligible to predeposit autologous blood. Autologous blood d o n o r patients and non-

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autologous donor patient records were audited for: units of autologous blood requested, units of autologous blood stored, recorded hematocrits (Hct), deferrals for inadequate Hct (=<34%) (19) or other reasons, and transfusions subsequently received (units of autologous and homologous blood).

Autologous Blood Predeposit Program The autologous blood predeposit program of The University Itospitals of Cleveland Component Therapy Unit has been previously described (15, 32). Orthopedic patients considered eligible for autologous blood donation in this study were those scheduled for surgical procedures in whom blood type and crossmatch were requested. Every patient scheduled for elective orthopaedic surgery is given a packet of informational material that includes: a letter (from LTG) introducing our autologous blood program to the patient, a brochure describing the hospital autologous blood program, and a brochure describing the autologous blood program of our regional blood center. Guidelines established by the American Association of Blood Banks (AABB) for autologous blood donation (13) are followed. The number of autologous blood units to be procured is determined by each patient's surgeon, generally corresponding to the number of homologous units requested for type and crossmatch. A previous audit of autologous blood donors for elective orthopedic surgery at our institution has shown the following percentage of autologous blood donors by procedural categories: of 175 elective orthopedic procedures with autologous blood donation, laminectomies comprised 31/ 175 (18%) of procedures, spine fusions 31/175 (21%), total hip procedures 53/175 (30%), total knee procedures 30/175 (17%) and miscellaneous 23/175 (13%) (15). Ferrous sulfate 325 mg, to be taken 3 times daily by mouth, is prescribed for each patient. Blood units are stored as whole blood in citratephosphatedextrose-adenine (CPDA-I) with a 35day outdate, or as packed red blood cells in adeninedextrose-saline mannitol (ADSOL) with a 42-day outdate.

Results

Autologous Blood Predeposit Activity During the study interval, 241 of 719 (34%) adult patients scheduled for joint arthroplasty surgery predeposited autologous blood. One hundred fifty-two

of 421 (36%) patients undergoing elective hip surgery and 89 of 298 (29%) patients undergoing elective knee surgery predeposited autologous blood. There was a marked increase in activity for both hip and knee procedures, however, with hip procedures showing the largest increases in autologous blood unit predeposit activity (Fig. 1). In the last 6 months audited, 56 of 77 (73%) hip procedures and 26 of 41 (63%) knee procedures were accompanied by autologous blood orthopaedic. Autologous blood units collected for all procedures at our hospital have increased from 61 to 1,825 units in the last 3 years. The contribution of the regional blood center has increased from virtually no autologous blood units (only 6 autologous donors) and 123/1,212 (10%) autologous blood units in the first 12 months of the audit to 271/913 (30%) in the last 6 months of the audit. Number of autologous blood donors has similarly increased over the last 3 years. The percentage of autologous blood donors scheduled for orthopaedic surgery who predeposit at the blood center compared to those who predeposit at the hospital, has increased from 6/26 (23%) in year 1, to 44/126 (35%) in year 2, to 129/283 (46%) in year 3. Patient characteristics for autologous blood donors who predeposit at the blood center compared to those who predeposit at the hospital were analyzed: 91/179 (51%) of blood center autologous blood donors were female, compared to 145/269 (54%) hospital autologous blood donors who were

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Fig. 1. Autologous blood (AB) predeposit programs: utilization for elective hip and knee surgery Over a 3-year period. The percent eligible patients who predeposited AB has increased from less than 5% in the first 6 months to over 60% in the last 6 months. Eligible patie.nts were defined as those adult patients (_->age 18) electively scheduled for a hip or knee procedure requiring general anesthesia and blood type and antibody screen or crossmatch.

Autologous Blood Donation in Orthopaedic Surgery female (no difference). Similarly, autologous blood donor age was no different in year 3 for blood center and hospital, 57.2 • 1.1 vs 55.7 • 1.3 years, respectively. When autologous blood donors were analyzed for travel distance from home to hospital, 75/127 (59%) autologous blood donors who predeposited at the regional blood center live > 10 miles from the hospital, compared to only 24/151 (16%) autologous blood donors who chose to predeposit at the hospital.

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Transfusion Practice The efficacy of the autologous blood predeposit program for avoiding the need for autologous blood transfusion is shown in Figure 2. A decrease in homologous blood transfusion in autologous blood donors.for both hip and knee surgery was seen over the 3-year audit. To analyze possible reasons for this decrease, mean autologous blood units donated per patient over the study interval were analyzed. No differences for mean autologous blood units per patient, male or female, for hip and knee procedures were noted. Number of autologous blood units donated per procedure for year 3 was 2.7 • 0.4 for knee and 3.1 • 0.2 for hip arthroplasty, respectively. As seen in Figure 2, during the last audit interval nonautologous blood donors undergoing elective hip and knee surgery were found to have a 73% and 71% risk of homologous blood transfusions, respectively. In contrast, autologous blood donors were found to have only an 18% and 12% likelihood of receiving homologous blood (P < .05), respectively.. Since the number of autologous blood units available for transfusion does not explain the marked and continued decrease in homologous blood exposure in autologous blood patients, a more likely reason is that surgeons have lowered their postoperative "transfusion trigger" hematocrit (6) and adopted a more conservative transfusion behavior in these patients (20), as well as in nonautologous'patients. This is seen by the decline in homologous blood exposure in the nonautologous patients (Figure 2). The contribution of autologous blood units to our transfusion service activity has increased significantly over the last 5 years. Percent autologous blood transfused has increased from a negligible amount in years 1 and 2; to 120/17,268 (0.8%) in year 3, when our program was part of two studies of preoperative donation autologous blood programs (7, 10); and to 552/9,372 (5.8%) in year 5, representing a 10-fold increase in just the last 2 years. Autologous

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Fig. 2. Efficacy of autologous blood donation. Homologous blood transfusion is shown for autologous blood patients versus nonautologous patients. Percent patients transfused with homologous blood has remained above 70% for nonautologous patients but has decreased to 1218% for autologous blood patients undergoing knee and hip procedures, respectively.

blood transfusions represented 510/1,193 (43%) of all blood transfusions given to orthopaedic surgical patients at our hospital in the last year audited.

Discussion The previously recognized risks of posttransfusion hepatitis, hepatitis B (16) and non-A, non-B hepatitis (1, 29) has stimulated interest in autologous blood transfusion in orthopaedic surgery for over 20 years (5, 31). More recently, AIDS has been the driving force behind increasing patient requests for alternatives to homologous blood transfusion. These alternatives now include: no transfitsion, autologous transfusion, and designated (blood donor is known

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to transfusion recipient) transfusion (14). Despite a renewed interest in autologous blood donation for orthopaedic surgery (28), however, this practice was shown to be underutilized (30). A more recent study showed that blood loss in major joint arthroplasty, while lower for cemented hip and knee arthroplasties compared to noncemented prostheses, remains substantial (17). One study involving a small number of patients has demonstrated the efficacy of autologous blood donation in eliminating the need for homologous blood transfusions for elective joint arthroplasty in 62% of a series of 50 patients (35). This report did not comment on the homologous transfusion rate for a control group of nonautologous donors, but did conclude that "this method of (autologous blood) replacement should be considered" for elective joint arthroplasty surgery. Our present study has demonstrated that this previously underutilized transfusion practice has now become a "standard of practice" in terms of both utilization and efficacy. Over the last 3 years audited, participation in autologous blood donation has increased from less than 5% of eligible patients to 73% and 63% of patients scheduled for hip and knee arthroplast surgery, respectively. The efficacy of this intervention has also been demonstrated, with 82% and 88% avoidance of homologous blood transfusion for hip and knee surgery, respectively. This is in comparison to a previous report of 62% efficacy for aut01ogous blood donation (35). Other alternatives to reduce homologous blood exposure have also been advocated. While preoperative autologous donation represents good transfusion practice, designated donation remains controversial (7, 10, 11, 22, 24). While a previous report felt that designated blood donation was desirable as an additional alternative source of blood for patients undergoing joint arthroplasty surgery (35), we have demonstrated previously (10) that this practice is more "form than substance" and is ineffective in eliminating the need for homologous blood in elective orthopaedic surgery. Instead, maximizing autologous blood donation by lengthening the blood storage interval .(15) and/or therapy with recombinant human erythropoietin (13) remain the preferred alternatives. The role of intraoperative (33) and postoperative (8, 27) autologous blood salvage and reinfusion for joint arthroplasty is in evolution. In our study these alternative, interventions were not employed during the interval studied. Additional blood conservation techniques, such as collagen application during arthroplasty, have also been described (34).. While

these interventions provide further opportunities to reduce or eliminate homologous blood transfusion in this setting, the efficacy of preoperative autologous blood donation in eliminating the need for homologous blood in 82%-88% of patients during the last 6 months of our study suggests that these other techniques are best utilized in patients who are unable to donate the amount of autologous blood requested by their surgeon (9). These could include such patients as those with anemia, small body stature (and blood volumes) including pediatric patients, and patients asked to donate => 4 autologous blood units (12, 13), or patients unable to predeposit because of associated medical risks (26). Approximately 70% of patients undergoing hip or knee procedures now choose to predeposit autologous blood, with utilization continuing to increase. The rate of rise is slowing and there are several possible reasons why utilization will not achieve 100%. First, some joint procedures, while Considered elective, may be scheduled within 1 week of initial consultation for surgical reasons and thus render significant autologous blood predeposit as impractical. Second, some joint surgery patients may not be considered appropriate for autologous blood predeposit because of medical reasons: orthopaedic malignancies, aortic stenosis, congestive heart failure, significant cardiac arrhythmias, unstable angina, inadequate vascular access, or preexisting anemia (26). Third, many patients are referred to tertiary care institutions such as ours from long distances; while geographic distance does n o t prevent autologous blood predeposit, it makes the logistics of autologous blood predeposit more complex for patients and referring physicians. These patients would be particularly appropriate candidates for alternative blood conservation interventions such as postoperative autologous blood salvage and reinfusion (8, 27), intraoperative salvage (33), and/or recombinant human erythropoietin therapy (13). In addition to changing orthopaedic transfusion practice and homologous blood exposure, autologous blood predeposit has had an impact.on the blood bank transfusion service. Autologous blood transfusion has increased 10-fold over just 2 years, now representing 6% of all transfused red blood cells at our hospital. With a further doubling of autologous blood predeposit activity, our program utilization will be in the range of maximal utilization calculated from the multicenter study of 10-14% (21, 30). As demonstrated in this study, this increase has occurred because of the evolution of autologous blood predeposit from a widely endorsed but un-

Autologous Blood Donation in Orthopaedic Surgery derutilized transfusion practice (30) into one that has n o w become a standard of practice in joint surgery: in the last audit interval, over 43% of all red blood cells transfused to elective orthopaedic surgery patients were autologous blood units. Only 44 of 703 (6%) units of autologous blood procurred in this study were not subsequently transfused, so that "over utilization" (unnecessary donation of autoiogous blood for procedures associated with little expectation of blood usage) is not a concern in this group of patients. Furthermore, issues of blood inventory are obviated by a standard practice of supplying anticipated future blood needs for elective surgery with autologous blood (9, 30). Finally, autologous blood predeposit for elective orthop.aedic surgery has had an impact on the regional blood center. While current estimates are that autologous blood units represent only 2% of blood collected nationally (3), blood centers have clearly been able to respond to both patient requests for this servicq and the increased logistical demands of a specialized blood inventory product. In our 3-year study, the percentage of autologous blood donors for Drthopaedic surgery w h o chose to donate at the blood center has increased from 23% to 46%. Our study thus indicates that both blood centers and hospitals are expanding their autologous blood pro~uremeflt programs in recognition of the standard of tare this practice represents to patients and orthopaedic surgeons.

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ST: Postoperative blood salvage using the cell saver after total joint arthroplasty. J Bone Joint Surg 71:823, 1989 Goodnongh LT: Autologous blood donation. JAMA 259:2404, 1988 Goodnough LT: Directed blood procurement does not benefit patients who are already enrolled in the autologous blood predeposit program. Am J Clin Pathol 92:484, 1989 Goodnough LT, Bravo JR, Hsueh Y et al: Red blood cell mass in autologous and homologous blood units: implications for risk/benefit assessment of antologous blood "'crossover" and directed blood transfusion. Transfusion 29:821, 1989 Goodnough LT, Brittenham G: Limitations of the erythropoietic response to serial phlebotomy: implications for autologous blood donor programs. J Lab Clin Med 115:28, 1990 Goodnough LT, Rudnick S, Price T, et al: Increased collection of autologous blood preoperatively by recombinant human erythropoietin the[apy. N Engl J Med 321:1163, 1989 Goodnough LT, Shuck J: Blood transfusion in elective surgery: review of risks, options, and informed consent. Am J Surg June, 1990 Goodnough LT, Wasman J, Corlucci K, Chemosky A: Limitations to donating adequate autologous blood prior to elective orthopaedic surgery. Arch Surg 124:494, 1989 ,Grady GF, Bennett AJE, the National Transfusion rtepatitis Study Group: Risk of post-transfusion hepatitis in the United States. JAMA 22O:692, 1972 ttays MB, Mayfield JF: Total blood loss in major joint arthroplasty. J Anhroplasty 3:$47, 1988 Holland P (ed): Standards for blood banks and transfusion services p. 5. (12th edition), American Association of Blood Banks, Arlington, VA, 1987 Holland P (ed): Standards for Blood Banks and Transfusion Services p. 39. (12th edition), American Association of Blood Banks, Arlington, VA, 1987 Hull A, Wasman J, Goodnough LT: The effects of an autologous blood education program on physician transfusion behavior. Academic Medicine 64:681, 1989 Kruskall MS, Glazer EE, Leonard JJ et al: Utilization and effectiveness of a hospital autologous preoperative blood donor program. Transfusion 26:335, 1986 Kmskall MS, Umlas J: Acquired immunodeficiency syndrome and directed blood transfusions. Arch Surg 123:23, 1988 Mintz P: Autologous transfusion endorsed. JAMA 254:507, 1985 Page PL: Directed blood donations: con. Transfusion. 29:65, 1989 President's Commission Report on Human Immunodeficiency Virus (HIV) Infection, June 3, 1988 Sayers MH: Autologous blood donation by cardiac surgery patients: wisdom or folly? p. 114. In: Maffei L, Thurer R, (eds.) Autologous blood transfusion: cur-

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rent issues. Arlington, VA, American Association of Blood Banks, 1988 Semkiw LB, Schurman DJ, Goodman SB, Woolson ST: Postoperative blood salvage using the cell saver after total joint arthroplasty. J Bone Joint Surg 71A:823, 1989 Stanisavijevic S, Walker Rtl, Bartman CR: Autologous blood transfusion in total joint arthroplasty. J Arthroplasty 1:207, 1986 Stevens CE, Aach RD, Hollinger FB et al: ttepatitis B virus antibody in blood donors and the occurrence of non-A, non-B hepatitis in transfusion recipients. Ann lntem Med 101:733, 1984 Toy PTCY, Strauss RG, Stehling LC et a]: Predeposit autologous blood for elective surgery: a multicenter study. N Engl J Med 316:517, 1987

31. Turner RS:'Autologous blood for surgical autotransfusion. Proceedings of the American Academy of Orthopaedic Surgeons. J Bone Joint Surg 50A:834, 1968 32. Wasman J, Goodnough LT: Autologous blood donation for elective surgery: effect on physician transfusion behavior. JAMA 258:3135, 1987 33. Wilson W J: Interaoperative autologous transfusion in revision total hip arthroplasty. J Bone Joint Surg 71:823, 1989 34. Wittman FW, Ring PA: Reduction in blood loss in total hip arthroplasty using topical collagen. J Arthrop]asty 4:253, 1989 35. Woolson ST, Marsh JS, Tanner JB: Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery. J Bone Joint Surg 69:325, 1987