Reducing the risk of allogeneic blood transfusion
=================================================

* Battista Borghi
* Hanna van Oven

The restricted use of allogeneic blood transfusions has been accepted throughout the world as important in reducing risk, particularly of the transmission of infectious diseases.1 In orthopedic surgery reduced use of allogeneic transfusions has been shown to prevent both early2 and late3 postoperative infection.

In this issue (page 310) Brian Feagan and colleagues describe transfusion practices and blood conservation strategies used in 19 hospitals across Canada for patients undergoing elective total hip or knee arthroplasty during 1998/99.4 Of the 4535 patients whose charts they reviewed, 18.6% (range 1.3%–66.0%) predonated blood before their procedure, even though 57.9% were eligible to do so. Not surprisingly, the rate of allogeneic transfusions was much lower among those who predonated their blood than among those who did not (14.1% v. 30.6%).

Although the rate of autologous blood donation was higher than that in a similar study by the authors in 1995/96,5 it is striking that other methods for avoiding allogeneic transfusions are still being used infrequently. In only 2.4% of the cases in the current study were alternative blood conservation techniques such as normovolemic hemodilution and intra- and postoperative red blood cell salvage used.

As others have shown, including Feagan and coauthors, it is possible with autologous predonation alone to reduce dramatically the need for allogeneic transfusions.4,6,7,8 In other countries, various blood conservation programs are in use, and studies have shown that autologous donation, intraoperative blood salvage and postoperative blood salvage, alone or in combination, have reduced the rate of allogeneic transfusion to as low as 8%.3,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23 Table 1 summarizes the allogeneic transfusion rates of studies in which various combinations of blood conservation techniques were used.24

View this table:
[Table1](http://www.cmaj.ca/content/166/3/332/T1)

Table 1. 

With intraoperative blood salvage, uncoagulated blood is aspirated during surgery and collected in a bag connected to the inferior edge of the surgical wound and then into a reservoir. If the hemoglobin concentration falls by more than 20 g/L (or less if the risk of allogeneic transfusion is high, as in cases of pre-existing anemia or cardiovascular disease, for example) the red blood cells are concentrated, washed and reinfused with the use of an autotransfusion device (e.g., the Dideco Compact Advanced, Dideco S.p.A., Mirandola Modena, Italy) attached to the reservoir.20 If there is postoperative bleeding, the blood can be salvaged with the use of a recovery device (e.g., Dideco Recovery BT 797, Dideco S.p.A.) and, after sedimentation and microfiltration, reinfused during the first 8 hours after surgery.

The reinfusion of predonated blood should be spread out over the first 3 days after the operation. The decrease in hemoglobin concentration in the first 2 days, as a consequence of this delay, allows increased production of endogenous erythropoietin25 and reduces the need for allogeneic transfusion.26 Units of allogeneic blood are transfused only if there is symptomatic anemia or the hemoglobin concentration is less than 60 g/L (100 g/L in patients with cerebrovascular damage or heart disease) and only after all available autologous blood has been used and any concomitant hypovolemia has been corrected with crystalloid or colloid solution.18,19 After each unit of allogeneic blood is transfused, the patient's clinical situation needs to be checked and the need for another transfusion evaluated.18

The quality of red blood cells salvaged with the Dideco Compact Advanced intraoperative salvage apparatus and the Dideco Recovery BT 797 postoperative salvage device, as determined by the proportion of cells that are damaged, appears to be similar to the quality of red blood cells collected preoperatively and refrigerated at 4οC for 21 days.27 In addition, compared with stored autologous blood, salvaged blood is more resistant to changes in osmotic pressure and has higher concentrations of 2,3-diphosphoglycerate and higher physiologic concentrations of potassium.28 This level of quality explains why there is no correlation between the amount of intra- and postoperative blood lost and salvaged and the need for allogeneic transfusion.20

On the basis of personal experience and the data in the literature, including the findings of Feagan and coauthors, it is clear that the assessment of expected and tolerated blood loss helps to define transfusion needs. Methods to avoid allogeneic transfusion include autologous donation before elective surgery; intravenous administration of iron if necessary; use of exogenous erythropoietin in addition to or, in the case of Jehovah's witnesses for example, as an alternative to autologous donation;24 intraoperative blood salvage and reinfusion if the hemoglobin concentration falls by more than 20 g/L; hypotensive epidural anesthesia to achieve arterial pressure of about 50 mm Hg;29 monitoring of postoperative bleeding and, if blood loss exceeds 200 mL, reinfusion of salvaged red blood cells during the first 8 hours after surgery; antithromboembolic prophylaxis in doses adapted to body weight and hemocoagulation; and reinfusion of predonated autologous blood spread out over the first 3 days after surgery. In order to apply and integrate these methods and minimize complications related to surgery, cooperation among anesthetists, surgeons and transfusionists is indispensable in the perioperative management of patients.

𝛃 See related article page [310](http://www.cmaj.ca/lookup/volpage/166/310)

## Footnotes

*   *Contributors:* Both authors contributed substantially to the drafting and revising of the manuscript.
    
    *Competing interests:* None declared.

## References

1.  1. Spahn DR, Casutt M. Eliminating blood transfusions: new aspects and perspectives. Anesthesiology 2000;93:242-55.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00000542-200007000-00035&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10861168&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000087894500031&link_type=ISI) 

2.  2. Murphy P, Heal JM, Blumberg N. Infection or suspected infection after hip replacement surgery with autologous or homologous transfusion. Transfusion 1991;31:212-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1046/j.1537-2995.1991.31391165169.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=2003322&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1991FB96100006&link_type=ISI) 

3.  3. Magrini Pasquinelli F, Binazzi R, Borghi B, Gargioni G. Autotransfusion with intra- and postoperative blood recovery in prosthetic hip surgery. A study conducted on 1368 cementless prostheses. Chir Organi Mov 1997;82(3):249-61.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9494242&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

4.  4. Feagan BG, Wong CJ, Johnston WC, Arellano R, Colterjohn N, Karkouti K, et al. Transfusion practices for elective orthopedic surgery. CMAJ 2002;166 (3):310-4. Available: [www.cma.ca/cmaj/vol-166/issue-3/0310.asp](http://www.cma.ca/cmaj/vol-166/issue-3/0310.asp)
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjYvMy8zMTAiO3M6NDoiYXRvbSI7czoyMDoiL2NtYWovMTY2LzMvMzMyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  5. Feagan BG, Wong CJ, Lau CY, Wheeler SL, Sue-A-Quan G, Kirkley A. Transfusion practice in elective orthopaedic surgery. Transfus Med 2001;11: 87-95.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1046/j.1365-3148.2001.00291.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11299025&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000168273900004&link_type=ISI) 

6.  6. Borghi B, Fabozzi A, Lari S, Elmar K, Chesi R. New techniques of autotransfusion in hip surgery. In: Orau G, Lanoli G, editors. *Proceedings of the 1st International Postgraduate Course in Anaesthesia and in Intensive Care*. Galatina (Lecce, Italy): Salentina; 1985. p. 771-6.
    
    

7.  7. Woolson ST, Marsh JS, Tanner JB. Transfusion of previously deposited autologous blood for patients undergoing hip replacement surgery.J Bone Joint Surg Am 1987;69:325-8.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=3818698&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

8.  8. Thomson JD, Callaghan JJ, Savory CG, Stanton RP, Pierce RN. Prior deposition of autologous blood in elective orthopaedic surgery.J Bone Joint Surg Am 1987;69:320-4.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=3818697&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

9.  9. MacFarlane BJ, Marx L, Anquist K, Pineo G, Chenger J, Cassol E. Analysis of a protocol for an autologous blood transfusion program for total joint replacement surgery. Can J Surg 1988;31:126-9.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=3349376&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

10. 10. Wilson WJ. Intraoperative autologous transfusion in revision total hip arthroplasty. J Bone Joint Surg Am 1989;71:8-14.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=2913006&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

11. 11. Turner RH, Capozzi JD, Kim A, Anas PP, Hardman E. Blood conservation in major orthopedic surgery. Clin Orthop 1990;256:299-305.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=2364616&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

12. 12. Slagis SV, Benjamin JB, Volz RG, Giordano GF: Postoperative blood salvage in total hip and knee arthroplasty. A randomised controlled trial.J Bone Joint Surg Br 1991;73(4):591-4.
    
    

13. 13. Woolson ST, Watt JM. Use of autologous blood in total hip replacement. A comprehensive program. J Bone Joint Surg Am 1991;73:76-80.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1985997&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

14. 14. Dieu P, Goulard M, Delelis D, Dumora D, Pascarel X. Blood saving in bone prosthetic surgery. Apropos of 426 cases. [French] Cah Anesthesiol 1992;40 (6) :403-5.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1477754&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

15. 15. Pluvinage C, Preant J. Postoperative autotransfusion in total hip and knee prostheses. Cah Anesthesiol 1992;40(4):241-5.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1477739&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

16. 16. Borghi B, Bassi A, De Simone N, Laguardia AM, Formaro G. Autotransfusion: 15 years experience at Rizzoli Orthopaedic Institute.Int J Artif Organs 1993;16S-5:241-6.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8013998&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

17. 17. Borghi B, de Simone N, Formaro G, Ghermandi C, Vitullo F, Pignotti E. Methods of blood saving in revision surgery of the hip.Chir Organi Mov 1994; 79(4):361.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7614877&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

18. 18. Borghi B, Bassi A, Grazia M, Gargioni G, Pignotti E. Anaesthesia and autologous transfusion. Int J Artif Organs 1995;18:159-66. 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7499019&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

19. 19. Caroli GC, Borghi B, Bassi A, et al. Clinical aspects and results of blood saving at the Rizzoli Orthopaedic Institute. Minerva Anestesiol 1996;62(4 Suppl 1): 105-16.
    
    

20. 20. Borghi B, Pignotti E, Montebugnoli M, Bassi A, Corbascio M, de Simone N, et al. Autotransfusion in major orthopaedic surgery: experience with 1785 patients. Br J Anaesth 1997;79(5):662-4.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiYnJqYW5hIjtzOjU6InJlc2lkIjtzOjg6Ijc5LzUvNjYyIjtzOjQ6ImF0b20iO3M6MjA6Ii9jbWFqLzE2Ni8zLzMzMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

21. 21. Borghi B, Fanelli G, Celleno D. Autotransfusion with predeposit-haemodilution and perioperative blood salvage: 20 years of experience. Int J Artif Organs 1999; 22:230-4.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10466955&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

22. 22. Grosvenor D, Goyal V, Goodman S. Efficacy of postoperative blood salvage following total hip arthroplasty in patients with and without deposited autologous units. J Bone Joint Surg Am 2000;82(7):951-4.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10901309&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

23. 23. Borghi B, Casati A. Incidence and risk for allogenic blood transfusion during major joint replacement using integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia. Eur J Anaesthesiol 2000;17(7):411-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1046/j.1365-2346.2000.00693.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10964142&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

24. 24. Borghi B, Stagni F, Bacchilega I. Blood salvage techniques to avoid homologous blood transfusion in orthopaedic surgery. Intern Med 2001;9:30-5.
    
    

25. 25. Borghi B, Alleva R, Ghermandi C, Pratelli L, Bonini AM. Intensive predeposit-hemodilution autologous blood donation and IOBS increase in erythropoietic levels in patients undergoing hip arthroplasty.Int J Artif Organs 1998; 21 (3):171-3.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9622116&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

26. 26. Burbi L, Gregoretti C, Borghi B, Pignotti E. Effects of predeposit and intentional perioperative haemodilution on blood saving program in major orthopaedic surgery. Int J Artif Organs 1999;22:635-9.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10532433&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

27. 27. Alleva R, Ferretti G, Borghi B, Pignotti E, Bassi A, Curatola G. Physico-chemical properties of membranes of recovered erythrocytes in autologous blood transfusion: a study using fluorescence technique. Transfus Sci 1995;16 (3): 291-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/0955-3886(95)00033-T&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10159887&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 

28. 28. McShane AJ, Power C, Jackson JF, Murphy DF, MacDonald A, Moriarty DC, et al. Autotransfusion: quality of blood prepared with a red cell processing device. Br J Anaesth 1987;59(8):1035-9.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiYnJqYW5hIjtzOjU6InJlc2lkIjtzOjk6IjU5LzgvMTAzNSI7czo0OiJhdG9tIjtzOjIwOiIvY21hai8xNjYvMy8zMzIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

29. 29. Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand 1996;67(1):91-107.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.3109/17453679608995620&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8615115&link_type=MED&atom=%2Fcmaj%2F166%2F3%2F332.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1996TW33500025&link_type=ISI)