Autologous Blood Transfusion Reduces Post-Operative Blood Transfusion Following Total Hip Replacement

Abstract

Background: Allogenic blood transfusions are expensive and associated with risks and complications such as transmission of infections and incompatibility reactions. Aim: The objective of this study was to evaluate the efficacy of autologous blood transfusion in reducing the need for allogenic blood requirement after total hip replacement and also the cost benefit involved. Method: A retrospective case notes analysis of 178 consecutive patients undergoing total hip replacements from 2006 to 2007 were carried out. 73 patients belonged to Bellovac® ABT (Astra Tech) drains for post-operative blood salvage group (ABT group) and 105 patients belonged to standard Bellovac® (Astra Tech) vacuum drains group (Non-ABT group). Pre and post-operative haemoglobin (Hb) were compared between ABT and Non-ABT group in relation to type of surgery and anaesthesia. Results: 20 out of the 73 (27.3%) patients in ABT group and 45 out of 105 (42.8%) in Non-ABT group required blood transfusion (p=0.035). Forty six units (0.63 units per person) in ABT group and 106 units (1 unit per person) in Non-ABT were transfused in total (p=0.03). The average pre and post-operative Hb in ABT group were 13.1 and 9.6 while in Non-ABT group were 13.4 and 9.4 respectively. Conclusion: Autologous blood transfusion caused a reduction in the number of patients requiring blood transfusion and also reduced the amount of units transfused.

Full text

Autologous Blood Transfusion Reduces Post-Operative Blood Transfusion
Following Total Hip Replacement
Abdul Nazeer Moideen1*, Lara Elizabeth McMillan1 and George Zafiropoulos2
1Welshbone, South Wales Orthopaedics Research Network, Wales, UK
2Department of Trauma and Orthopaedics, Prince Charles Hospital, Merthyr Tydfil, UK
*Corresponding author: Abdul Nazeer Moideen, Welshbone, South Wales Orthopaedics Research Network, Wales, UK, Tel: 02920748044; E-mail:
anmoideen@doctors.net.uk
Received date: February 11, 2017; Accepted date: March 20, 2017; Published date: March 26, 2017
Copyright: © 2017 Moideen AN, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Allogenic blood transfusions are expensive and associated with risks and complications such as
transmission of infections and incompatibility reactions.
Aim: The objective of this study was to evaluate the efficacy of autologous blood transfusion in reducing the need
for allogenic blood requirement after total hip replacement and also the cost benefit involved.
Method: A retrospective case notes analysis of 178 consecutive patients undergoing total hip replacements from
2006 to 2007 were carried out. 73 patients belonged to Bellovac® ABT (Astra Tech) drains for post-operative blood
salvage group (ABT group) and 105 patients belonged to standard Bellovac® (Astra Tech) vacuum drains group
(Non-ABT group). Pre and post-operative haemoglobin (Hb) were compared between ABT and Non-ABT group in
relation to type of surgery and anaesthesia.
Results: 20 out of the 73 (27.3%) patients in ABT group and 45 out of 105 (42.8%) in Non-ABT group required
blood transfusion (p=0.035). Forty six units (0.63 units per person) in ABT group and 106 units (1 unit per person) in
Non-ABT were transfused in total (p=0.03). The average pre and post-operative Hb in ABT group were 13.1 and 9.6
while in Non-ABT group were 13.4 and 9.4 respectively.
Conclusion: Autologous blood transfusion caused a reduction in the number of patients requiring blood
transfusion and also reduced the amount of units transfused.
Keywords: Total hip replacement; Retransfusion drains; Autologous
blood transfusion
Introduction
ere were around 61,450 total hip replacement (THR) done in
England and Wales in 2006 [1]. Following total hip or knee
replacement around 750 ml of blood loss is common [2]. Aer primary
THR, there is 30% to 40% increased rate of homologous blood
transfusion [3]. ere are a number of risks associated with
homologous blood transfusion. In 1980s healthcare workers became
aware of risks of transfusion of blood borne infection following
discovery of human immunodeciency virus (HIV). Transfusion of
blood borne diseases including HIV, parvovirus, cytomegalovirus,
hepatitis has been well documented [4]. In recent times there has been
concerns regarding transmission of a variant of Creutzfeldt Jacob
disease following blood transfusion in the U.K. Transfusion of
homologous blood is also associated with immunologic reactions such
as transfusion related acute lung injury, acute haemolytic reaction,
anaphylactic reaction and febrile reactions [5]. Clerical error is also a
big risk occurring up to 1 in 20,000 blood transfusions [6].
Several techniques have been used to reduce homologous blood
transfusion. ey include pre-operative donation, intra and post-
operative salvage, and the use of recombinant erythropoietin.
Predonation of autologous blood sometimes can be unnecessary owing
to non-requirement of blood in the post-operative period. is could
lead to unnecessary wastage and high nancial cost of autologous
donation. It has been reported that the cost of discarded autologous
blood to be around $36 million annually in the United States [7]. In
intra and post-operative salvage, the shed blood can be returned aer
ltration (unwashed) or aer treatment in a cell saver (washed).
Transfusion of unwashed blood is relatively simple and inexpensive
whereas transfusion of washed cells requires expensive cell saver
machine.
In our institution autologous blood drainage has been used
successfully for total knee replacements (TKR). But for primary THR
usage of autologous blood drainage system has been controversial.
erefore in this study we have evaluated a post-operative blood
salvage and retransfusion system following primary total hip
replacement. e aim of the study was to determine the ecacy of the
autologous blood transfusion in the reducing the need for homologous
blood requirement and the cost benet involved.
Patients and Methods
e medical records of 178 consecutive patients who underwent
primary THR for osteoarthritis from January 2006 to June 2007 were
reviewed respectively to assess the ecacy of post-operative cell
Journal of Arthritis Moideen et al., J Arthritis 2017, 6:2
DOI: 10.4172/2167-7921.1000235
Research Article OMICS International
J Arthritis, an open access journal
ISSN:2167-7921
Volume 6 • Issue 2 • 1000235

salvage system. Patients who were on anticoagulants prior to surgery,
revision THR and THR for fracture neck of femur were excluded from
the study. At pre-operative assessment, patients were advised to
discontinue aspirin or clopidogrel seven days before surgery. Pre-
operative Hb was recorded. Four senior consultants performed all the
surgery using anterolateral approach. All patients had three drains – 2
deep to fascia lata and one supercial to it. One of the surgeons (GZ)
used Bellovac® ABT (Astra Tech) drains for post-operative blood
salvage (ABT group) (n=73). Other surgeons used standard Bellovac®
(Astra Tech) vacuum drains (Non-ABT group) (n=105).
Bellovac® ABT set is a closed circuit system consisting of suction,
lters and 500 ml of autotransfusion bag. Blood passes through a 200
µm lter before collecting into the autotransfusion bag. During
transfusion, blood again passes through two concentric lters in the
transfusion set measuring 40 µm and 80 µm. No anticoagulants are
used due to low brinogen content in the blood collected post-
operatively. Bellovac® ABT system was not used if there was infection,
malignancy or contamination of the operating site. In the post-
operative period, the blood collection was started immediately upon
wound closure if prosthesis used was uncemented or aer 30 minutes
for cemented prosthesis. Autologous blood was retransfused to the
patient via the closed circuit when 500 ml blood was collected or
within 6 hours (whichever was earliest). A recommended maximum of
1500 ml can be transfused via this system. Patients who drained less
than 200 ml over 6 h were not retransfused. Retransfusion of collected
blood is contraindicated if there is signicant amount of air leakage
into the collecting bag. Blood drained aer 6h were discarded. All
drains were removed 2 days post-surgery. e protocol was devised
following manufacturer’s recommendation.
Patients in both groups underwent identical post-operative protocol
including three doses of post-operative antibiotics. All patients
received 40 mg of enoxaparin for 5 days post-surgery and 2 mg (if <60
yrs) or 1mg (if >60 yrs) of warfarin for 6 weeks as per the anti-
thrombotic prophylaxis protocol of the hospital. Patients received
homologous transfusion if their haemoglobin (Hb) level dropped
below 8 g/dl or if they develop symptomatic anaemia (exertional
breathlessness, angina, fatigue or dizziness). All patients were
monitored during autologous or homologous blood transfusion as per
hospital protocol.
e following parameters were recorded for each patient: age, sex,
type of prosthesis, type of drain, volume of autologous blood
transfused, volume of blood in vacuum drain on removal, units of
homologous blood transfused, length of stay in the hospital and
complications. Statistical analysis was performed using Statistical
Package for Social Sciences version 17 (SPSS Inc., Chicago, Illinois).
e Mann-Whitney U test (non-parametric data) was used for the
comparison of univariate means and chi-squared test for comparison
of categorical variables.
Results
ere were 73 patients in ABT group and 105 in Non-ABT group.
eir demographics, types of anaesthesia and prosthesis are shown in
Table 1. ere was no statistical dierence in the ages of two groups
(p=0.912). e mean duration of operation for ABT and Non-ABT
groups were 1.2 h and 1.4 h respectively. e mean length of stay for
ABT group was 13 days (6-107) and mean for Non-ABT group was
12.5 days (5-65). ere was no statistically signicant dierence
between the groups for length of stay (p=0.749). e average pre-
operative haemoglobin levels between the two groups did not dier
signicantly (13.1 and 13.4 respectively). Postoperative blood
measurement showed a signicant dierence in Hb drop between ABT
group (3.44 g/dl) and Non-ABT group (4.07 g/dl) (p=0.005) (Table 2).
ABT group (n=73) Non-ABT group (n=105)
Sex
Male 27 (37%) 46 (44%)
Female 46 (63%) 59 (56%)
Age (years) 68 (31-92) 69 (45-93)
Type of anaesthesia
General 5 (7%) 17 (16%)
Spinal 61 (83%) 66 (63%)
Epidural 7 (10%) 22 (21%)
Prosthesis
Cemented 3 (4%) 42 (40%)
Uncemented 44 (60%) 14 (13%)
Hybrid 26 (36%) 49 (47%)
Table 1: Patient demographics, type of anaesthesia and prosthetic type
ABT group
(n=73)
Non-ABT group
(n=105) p-value
Mean pre-operative
haemoglobin (g/dl) 13.1 (10-16.5) 13.4 (9.2-15.8) 0.173
Mean post-operative
haemoglobin (g/dl) 9.6 (5.8-13.6) 9.4 (5.7-13.6) 0.429
Mean change in
haemoglobin (g/dl) 3.4 (0.4-6.7) 4.1 (0.7-7.3) 0.005
Table 2: Pre- and post-operative haemoglobin levels and mean
dierence.
ABT group
(n=73)
Non-ABT group
(n=105) p-value
Volume in drains (ml) 302 (40-700) 438 (60-1550)
Volume retransfused (ml) 359 (150-700) n/a
No. of patients retransfused 56 (77%) n/a
Units of homologous blood
transfused 46 106
No. of patients transfused 20 (27%) 45 (43%) 0.035
Units transfused per person 0.67 1 0.03
Table 3: Drainage volume and transfusion for both groups.
In the ABT group, 56 patients (76.7%) were re-transfused a mean
blood volume of 360 ml (200-700); blood was discarded in 17 cases
(23.3%) of this group because of insucient volume. is is
Citation: Moideen AN, McMillan LE, Zafiropoulos G (2017) Autologous Blood Transfusion Reduces Post-Operative Blood Transfusion Following
Total Hip Replacement. J Arthritis 6: 235. doi:10.4172/2167-7921.1000235
Page 2 of 4
J Arthritis, an open access journal
ISSN:2167-7921
Volume 6 • Issue 2 • 1000235

comparable with other studies which reported mean re-transfusion
volumes of 264 ml and positive re-transfusion rates of 75.6% [8].
Among these, patients with uncemented prosthesis received an average
of 400 ml (200-700 ml), hybrid 300 ml (200-500 ml) and cemented
300ml (250-300 ml) of salvaged blood. Twenty patients in ABT group
(27.3%) and 45 patients in Non-ABT group (42.9%) received
homologous transfusion (χ2=4.44; p=0.035). In total 46 units (0.63
units per person) of homologous blood in ABT group and 106 units (1
unit per person) in Non-ABT were transfused (p=0.03) (Table 3).
ere were no complications associated with homologous or
autologous blood transfusion. One patient in ABT group was treated
for atrial brillation and two patients in Non-ABT group were treated
for chest infection.
Discussion
Increased awareness of morbidity and mortality associated with
homologous blood transfusion has led to research into alternatives to
blood transfusion. ey include erythrocyte induction using
recombinant human erythropoietin [8,9], tranexamic acid [10], pre-
operative donation [11], haemodilution [12], intra-operative [13] and
post-operative salvage [8]. However the best method to reduce the
need for blood transfusion following THR remains controversial.
Bellovac® ABT system is safe, simple to setup and use. It contains
three lters, a 200 µm lter which blocks large debris such as cell
fragments, clotted blood, bone substance and bone cement, 80 and 40
µm lters which traps tinniest of debris and clots. Questions have been
raised about the safety of the collected unwashed blood [14]. A study
done by Sinardi et al. [15] has shown blood collected with Bellovac®
ABT contained RBCs of normal morphology, with increased
concentrations of 2,3-DPG and ATP and therefore able to deliver
oxygen and energy to tissues. A study done by Hand et al. [16] has
shown that there was no evidence of methyl methacrylate monomer in
the systemic blood following transfusion of shed blood following
cemented TKR. Comparison of coagulation parameters in patients has
shown no signicant dierence in the measurement of antithrombin
III, aPTT, thromboplastin time, thrombin time and plasminogen in the
sera over time aer transfusion of autologous shed blood [17]. Several
studies have demonstrated an increase in concentration of complement
split products and cytokines levels such as C3a, SC5b, TNF-α, IL-1α,
IL-1β, IL-6 and IL-8 in shed blood, but only elevated IL-6 in plasma
following transfusion [18,19]. One of the most common side eects of
autologous blood transfusion is febrile reaction and it has been found
to be related to higher concentration of IL-6 in shed blood [20]. We did
not nd any such side eects with our study.
Many studies have shown that the use of ABT following TKR is
eective in reducing post-operative blood transfusion [21,22]. But
there has been very few studies involving ABT in primary THR
without the use of pre-operative donation or intra-operative salvage
[23,24]. In our study autologous blood transfusion using Bellovac® ABT
system has shown a signicant reduction in post-operative allogenic
blood transfusion following primary total hip replacement (42.9% to
27.3%; P=0.035) which are comparable to studies by Strumper et al.
[21] (47% to 34%) and Wynn Jones et al. [22] (46% to 26%). Patients
who received postoperative retransfusion also had a signicantly
smaller haemoglobin drop (dierence 0.63 g/dl; P=0.005) in the peri-
operative period. ere was an increase in mean blood volume
collected among uncemented implants compared to cemented
implants which was similar to the ndings of Hays and Mayeld [25].
During this study the cost of Bellovac® ABT system was £46.95 and a
unit of blood cost £132. Cost analysis has shown that there was a
reduction of 9% of the cost per person when Bellovac® ABT system was
used compared to vacuum drain (Table 4).
ABT group (n=73) Non-ABT group
(n=105)
Cost of drain (£) 46.95 16
Cost of unit of blood (£) 132 132
Units transfused per person 0.67 1
Cost of blood per person (£) 88.44 132
Total cost per person (£) 135.39 148
Table 4: Cost comparison between two groups.
Conclusion
is study conrms that the use of post-operative salvage
signicantly reduces the need for homologous blood transfusion
following primary total hip replacement. Bellovac® ABT system is cost
eective, easy and safe to use with no obvious complications.
erefore, in patients having primary total hip replacements with no
evidence of infection or cancer, the use of autologous blood
transfusion should be considered as it reduces the need for post-
operative blood transfusion.
Compliance with Ethical Standards
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Acknowledgement
We would like to thank all the consultants for contributing patients
and the audit department at the hospital for providing with case notes.
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Citation: Moideen AN, McMillan LE, Zafiropoulos G (2017) Autologous Blood Transfusion Reduces Post-Operative Blood Transfusion Following
Total Hip Replacement. J Arthritis 6: 235. doi:10.4172/2167-7921.1000235
Page 3 of 4
J Arthritis, an open access journal
ISSN:2167-7921
Volume 6 • Issue 2 • 1000235

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Citation: Moideen AN, McMillan LE, Zafiropoulos G (2017) Autologous Blood Transfusion Reduces Post-Operative Blood Transfusion Following
Total Hip Replacement. J Arthritis 6: 235. doi:10.4172/2167-7921.1000235
Page 4 of 4
J Arthritis, an open access journal
ISSN:2167-7921
Volume 6 • Issue 2 • 1000235