Journal of Orthopaedic Nursing (2008) 12, 179–180

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Journal ofOrthopaedic Nursing

Factors determining blood transfusion in patientsundergoing total knee arthroplasty: Cross-matchor group and save?

Kenneth Cheng MRCS (Edin) *, Andrew Christie MRCS (Edin),Clark Dreghorn FRCS (Orth)

Department of Trauma and Orthopaedic Surgery, Victoria Infirmary, Langside Road,Glasgow, G42 9TY, United Kingdom

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KEYWORDSBlood transfusion;Knee arthroplasty

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* Corresponding author. Tel.E-mail address: kc11eng@g

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: +44 14mail.com

Summary The aim of this study was to examine clinical characteristics of patientsundergoing elective total knee arthroplasty to ascertain whether it is possible toidentify subjects at high risk of post-operative transfusion.

�c 2008 Elsevier Ltd. All rights reserved.

Editor’s commentsThis is a small-scale study does not claim to show any substantive significance in its findings but is asking an important and commonquestion. It is a good example of a local study that raises awareness of the need to examine and change current practice and thenundertake further research with greater numbers of participants and control of variables. PD

Introduction

Orthopaedic surgery may be associated with sub-stantial blood loss necessitating transfusion oferythrocytes in either the perioperative or post-operative periods. Currently, allogeneic blood isused as the source of replacement blood howeverthis is not without its risks. Transfusion of alloge-neic erythrocytes has been associated withtransmission of infectious diseases, increasedpost-operative bacterial infection, immune sensiti-zation, transfusion-related acute lung injury andpotential for clinical error (Hill et al., 2003; Spahnand Casutt, 2000; Goldman et al., 1997). The po-

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1 201 6000.(K. Cheng).

tential for these adverse effects, high costs, andintermittent blood shortages therefore mandate awise use of allogeneic RBC transfusions. Currently,it has been estimated that 45% of autologous bloodcollected for patients undergoing elective knee orhip arthroplasty is wasted (Bierbaum et al., 1999).

The standard practice of routine cross-matchingof packed red cells for elective arthroplasty variesthroughout the United Kingdom. In our centre all pa-tients undergoing elective total knee arthroplasty(TKR) are routinely cross matched 2 units of blood.

Aim

The aim of this study was to examine clinical char-acteristics of patients undergoing elective total

rved.

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g/L) Subjects requiring

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180 K. Cheng et al.

knee arthroplasty to ascertain whether it is possi-ble to identify subjects at high risk of post-opera-tive transfusion.

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1

Mea

n pr

e-op

era

haem

oglo

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(m transfusion

Subjects notrequiring postoperativetransfusion

Figure 2 Mean pre-operative haemoglobin of subjectswho did or did not require transfusion.

Method

The case notes of 50 patients (34 female, 16 male,mean (SD) age 73.3 (8.2) years) who underwent to-tal knee arthroplasty, in an inner city teaching hos-pital were examined. Baseline demographics, pastmedical history and concurrent drug history werenoted.

Particular attention was paid to the use ofaspirin, other non-steroidal anti-inflammatorydrugs (NSAIDs) or warfarin.

Results

Out of the 50 patients 6 (12%) required transfusion(Fig. 1). Pre-operative haemoglobin (Hb) differedsignificantly between the two group with a meanHb in those requiring transfusion of 124.8(18.5) mg/L versus 137.9 (12.4), p = 0.026 (Fig. 2).Fifty percent of those transfused were on NSAIDsversus 27% in the non-transfused cohort. A weakbut non-significant correlation (reflecting lack ofsubjects) existed between transfusion and NSAIDuse, r = 0.161, p = 0.264. No association was foundwith aspirin use (r = 0.027, p = 0.853). No statisticaldifference was found in age of subjects betweenthose transfused and those not (p = 0.344).

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0%

10%

20%

30%

40%

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70%

80%

90%

100%

Perc

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Subjectsrequiring postoperativetransfusion

Subjects notrequiring postoperativetransfusion

Figure 1 Percentage of subjects who did and did notrequire post-operative transfusion.

Discussion

Only 12% of the patients reviewed required a post-operative blood transfusion. Predictive factors in-cluded a low pre-operative haemoglobin levelsand concurrent use of NSAIDs. This rate is consis-tent with previously reported rates in subjectsundergoing TKR (Glynn et al., 2006). This studydemonstrates that the routine cross-matching ofelective patients undergoing total knee arthro-plasty in the vast majority of cases is unnecessary.

Improved surgical techniques in total kneearthroplasty have decreased the requirement fortransfusions and the current practices of routinecross-matching for this elective period should bereviewed.

Conclusion

This study suggests that those with low pre-opera-tive haemoglobin levels and concurrent use of NSA-IDs constitute a high risk group for post-operativetransfusion.

References

Bierbaum, B.E., Callaghan, J.J., Galante, J.O., et al., 1999. Ananalysis of blood management in patients having a total hipor knee arthroplasty. J. Bone Joint Surg. 81, 2.

Glynn, A., McCarthy, T., McCarroll, M., Murray, M., 2006. Aprospective audit of blood usage post primary total kneearthroplasty. Acta Orthop. Belgica 72, 24–38.

Goldman, M., Remy-Prince, S., Trepanier, A., et al., 1997.Autologous donationerror rates inCanada.Transfusion 37, 523.

Hill, G.E., Frawley, W.H., Griffith, K.E., Forestner, J.E., Minei,J.P., 2003. Allogenic blood transfusion increases the risk ofpostoperative bacterial infection: a meta-analysis. J. Trauma54, 908–914.

Spahn, D.R., Casutt, M., 2000. Eliminating blood transfusions:new aspects and perspectives. Anaesthesiology 93, 242–255.

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