Perioperative Blood Transfusion Strategies in Orthopaedic Surgery: A Comprehensive Review and Analysis

Abstract

Introduction

Perioperative blood transfusions are necessary during orthopaedic surgery since it is linked with significant bleeding. Remember that receiving blood transfusions containing various blood components might lead to a number of problems. In order to draw conclusions on perioperative blood transfusion methods in orthopaedic surgery, including adjuvants, this literature analysis looks at the most recent data that are currently available.

Methods

Databases and other sources were searched for pertinent literature. The following databases were searched for recent evidence: MEDLINE, EMBASE, SCOPUS, PubMed, Google Scholar, the Cochrane Library, and Science Direct. Medical heading subjects (MeSH) were merged with Boolean operators such as OR, AND, and NOT, which restrict or broaden the scope of possible supporting evidence. The weight of the evidence supporting each conclusion was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

The included literatures cover a wide range of topics, including fracture type, perioperative bleeding management techniques like adjuvant therapies used to reduce problems from blood transfusions, and hemoglobin thresholds for blood transfusion.

Conclusion and Recommendations

Patients who are at danger of bleeding during surgery or who are anemic should be handled with medication, allogenic blood transfusions (restrictive type), adjuvants, and non-pharmacological methods such tourniquets and cell savers. Instead of relying just on one transfusion technique, healthcare personnel should consider the patient’s situation in depth and use a variety of transfusion tactics.

Keywords:

• anemia
• blood transfusion
• orthopedics
• perioperative
• strategies

Introduction

Orthopedic operations are difficult, regularly carried out procedures that involve extensive bleeding during the operation and blood transfusions afterward.¹ According to a Romanian study, 1,557,247 orthopaedic procedures were performed between 2001 and 2022.² The balance between bleeding and thrombotic events during the perioperative phase in orthopaedic surgery is very sensitive.³ Patients with bleeding had a higher risk of in-hospital mortality or readmission than those without; also, surgical bleeding risk increased stepwise with increasing perioperative cardiovascular risks when stratified by updated cardiac risk index.⁴

Perioperative blood management includes adjuvant therapies and blood transfusions. Blood transfusion is the term used to describe the perioperative delivery of blood and blood products such as autologous blood, allogeneic whole blood, red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. Adjuvant therapy includes drugs and treatments that limit or reduce blood loss so that allogeneic blood transfusions are not necessary.^5,6 Systemic side effects from transfusions include allergic reactions, acute lung injury due to transfusions, circulatory overload, graft-versus-host disease, and infections.^7–9

In regards to perioperative blood transfusions, there are basically two different schools of thought. These are transfusing at a hemoglobin threshold of 100 g/L (referred to as “liberal”) versus transfusing at a level of 70 g/L or less (referred to as “restrictive protocol”).^10,11

Orthopedic operations benefit from innovations that can ensure patient safety while minimizing the need for transfusions.¹² Restrictive transfusion policies may lower the need for transfusions and may prevent infections without increasing the likelihood of negative outcomes after major orthopedic surgery, according to moderately strong evidence.^13,14

Blood management is one of the facets of an orthopaedic surgical patient’s management that are not directly related to the surgical method but are nevertheless crucial for a successful outcome.¹⁵ Age, the kind of fracture, and the hemoglobin (Hb) level upon admission are the key variables influencing perioperative blood transfusion.¹⁶

Tranexamic acid is a safe and efficient pharmacological blood preservation medication when treating clinically significant hemorrhage.¹⁷

Since the target organ, the bone, has a propensity to bleed profusely and can be difficult to control due to its diffuse nature, increased transfusion rates are required. In addition, most of patients receiving these treatments are often elderly women, who tend to have more cardiovascular co-morbidities, lower hemoglobin levels, and smaller blood volumes than men.¹⁸

Accurate blood loss prediction enables risk-based patient counseling, target optimization, and projection of future transfusion needs.¹⁹ Patients have been treated before they reach a certain point of decline because intraoperative blood transfusion was linked to an increase in morbidity and mortality.²⁰ Owing to the prevalence of orthopaedic surgical procedures and the paucity of information in the literature, the review’s goal is to review current perioperative blood transfusion methods based on previously published research.

Methods

In accordance with the methodology used for the narrative review, relevant literature was looked up from databases and other sources. To locate recent evidence, the following databases were used: SCOPUS, PubMed, science direct, Google Scholar, Cochrane library, MEDLINE, and embase. By limiting or enlarging the range of potential supporting evidence, medical heading subjects (MeSH) were integrated with proximity operators and Boolean operators like OR, AND, and NOT. Perioperative AND blood AND transfusion, allogenic blood AND adjuvants, pharmacologic AND blood products AND bleeding management, autologous AND allogenic transfusion, anemia OR low hemoglobin level AND indication for blood transfusion, were terms used for searching in different databases. Endnote reference manager was used to remove duplications of extracted literatures from different sources. The review process was conducted in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) 2020²¹ (Figure 1). The strength of evidence supporting each conclusion was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.²²

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020. Adapted from Page MJ, McKenzie JE, Bossuyt PM et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ (Clinical research ed). 2021;372:n71. Creative Commons.²¹

Inclusion and Exclusion Criteria

We have incorporated randomized controlled trials, systematic reviews, meta-analyses, and observational studies on perioperative blood transfusion techniques for orthopaedic surgical patients that are published in English at any time into this narrative review. This review did not include any duplicate research, reports, commentary, full-text papers, brief communications, or letters to the editors.

Results

Identification of Studies

We have identified a total of 31, 174 studies from databases, registers, websites, organizations and citations searching. After removing duplicates, reviewing titles and abstracts, 61 studies were included in this review.

The total number of literatures identified through searching from data-bases and websites were 27,300 and 1,055 respectively. Among these evidences, duplications removed were 2045 and during screening phase with human, 25,625 literatures were excluded. Finally, this narrative review included 61 published papers (Figure 1).

Characteristics of Included Studies

The sample of studies that were part of the current review was displayed in the table below (Table 1).

Table 1 Summary of Sample Literatures Used in Conclusions

Author (s)	Year (publication)	Study Design	Objectives	Outcomes/Conclusions
Blankstein AR, et al^Citation1	2021	Retrospective cohort study	Transfusion practices in orthopaedic surgery for planning blood preparation	Evaluation of factors that contribute to transfusion used to inform perioperative planning and blood bank requirements
Gregory A. Nuttall, et al^Citation5	2006	Guidelines	To improve the perioperative management of blood transfusion and reduce the risk of adverse outcomes	Reviewing previous medical records, interviewing the patient, and reviewing hemoglobin/hematocrit test results should be part of a preoperative evaluation.
Pietris J^Citation11	2022	Literature review	Currently available studies on transfusion protocols	To conclude, further high quality study should be conducted.
Mitchell MD, et al^Citation14	2017	Meta-analysis	To compare transfusion thresholds for patients having hip and knee arthroplasty or hip fracture repair.	Restrictive transfusion practices reduce utilization of transfusions and may decrease infections without increasing adverse outcomes in major orthopedic surgery.
Saleh E, et al^Citation23	2007	Retrospective observational study	To measure the prevalence of anaemia among admissions presenting for elective major joint arthroplasty	Patients most likely to avoid transfusions with preoperative intervention are those with low haemoglobin undergoing revision hip surgery. Prevalence −20%.
Alcelik I, et al^Citation24	2012	Meta-analysis	To quantify the impact of tourniquet use for the prevention of intraoperative blood loss.	The total and intraoperative blood losses are less when using a tourniquet.
Zhu C, et al^Citation25	2019	Meta-analysis	To compare the pros and cons of restrictive versus liberal transfusion strategies undergoing hip fracture surgery	Clinicians should assess the patient’s condition and adopt different transfusion strategies.
Alsaleh K, et al^Citation26	2013	Meta-analysis	To evaluate the efficacy of preoperative administration of erythropoiesis-stimulating agents on hemoglobin level	Erythropoiesis-stimulating agents offer an alternative blood conservation method to avoid allogeneic blood transfusion in patients undergoing hip or knee surgery.
Xie J, et al^Citation27	2015	Meta-analysis	To determine hematological or clinical differences with the use of postoperative cell salvage.	Postoperative cell salvage is effective and safe to reduce the rate of transfusion after orthopedic procedures.
Lenet T, et al^Citation13	2022	Meta-analysis	To compare intraoperative red blood cell transfusion strategies and their impact on postoperative morbidity, mortality, and blood product use.	Intraoperative restrictive transfusion strategies decreased perioperative transfusions without added postoperative morbidity and mortality

Discussion

Despite being life-saving, blood transfusions (BT) are linked to morbidity, mortality, and longer hospital stays. The goal of patient blood management (PBM) is to reduce the need for transfusions by utilizing multidisciplinary and multimodal preventive strategies, which will ultimately enhance the clinical results for patients.²⁸

Various rates of transfusion were linked to orthopedic operations. The type of surgery has a big impact on how often red blood cells (RBCs) are transfused. Pre-emptive transfusion mitigation strategies can be facilitated by identifying procedures with the highest transfusion rates and further evaluating the factors that contribute to transfusion in groups that have previously been recognized as at-risk.¹ Based on the most recent data, this review reviewed the perioperative blood transfusion strategies for various orthopedic procedures.

Perioperative Blood Transfusion Strategies for Various Orthopedic Procedures

Prior to elective surgery, anemic patients must be identified and treated using strategies that will improve clinical results.²⁹ Age, sex, lower admission Hb level and patients with American Society of Anesthesiologists (ASA) score 3–4 were the factors.^30,31 Patients with low preoperative hemoglobin, low body mass index (BMI), or low estimated glomerular filtration rate (eGFR) have significantly higher individual risks for blood transfusions and immediate postoperative problems. Therefore, it has been advised that clinicians optimize patients with a low BMI during the preoperative period, aim for a preoperative Hb 13g/dL and an eGFR 60 mL/min.³²

Length of hospital stay (LOS) and post-operative infections were both considerably decreased by intravenous iron therapy (IVIT).³³ Hospitals typically manage iron deficiency anemia by administering intravenous iron prior to surgery, tranexamic acid during surgery, and strict transfusion guidelines afterward.³⁴

A restrictive red blood cell (RBC) transfusion technique is therefore preferred to a liberal transfusion strategy (hemoglobin threshold greater than 10 g/dL, typically greater than 8 g/dL), according to a number of studies³⁵ and a meta-analysis of a range of clinical specialties showed that restrictive transfusion decreased the RBC proportion by 43% but did not impact 30-day mortality or morbidity rate.³⁶ According to a meta-analysis, instead of just employing one transfusion technique, healthcare providers should carefully assess each patient’s condition and choose the most appropriate transfusion approach for them.²⁵

Preoperative anemia is prevalent in approximately 20 −25% of the patients undergoing elective total hip replacement surgery.²³

Hemoglobin (Hb) concentrations below 12 g /dL in females and 13 g /dL in males are considered anemic by the World Health Organization (WHO). Due to the lower total blood volume in women than in men, a 500 mL blood loss will have a bigger influence on hemoglobin levels, making this female 12 g /Dl threshold insufficient for lowering transfusion risk.³⁷ Therefore, regardless of gender, the conference suggested using the 13 g/ dL criterion. The results of the other study showed that hemodynamic instability or excessive bleeding, not hemoglobin (Hb) level, are the reasons for BT during orthopedic surgery.²⁸ Preoperative anemia has been linked to postoperative problems in several studies.^11,12,29,31

Strategies to reduce the need for blood transfusions during surgery have mostly concentrated on decreasing transfusion thresholds. The patient target Hb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l).³⁸ Further investigation into dietary inadequacies, chronic renal failure, and/or chronic inflammatory disorders should be done in the laboratory.³⁹ Erythropoiesis-stimulating agent (ESA) therapy should be utilized for anemic patients in whom nutritional deficiencies have been ruled out and/or repaired in addition to nutritional deficiencies being treated.⁴⁰

In patients undergoing bilateral hip arthroplasty, a higher preoperative hemoglobin level, the administration of tranexamic acid (TXA), and intraoperative autologous blood transfusion using a closed suction drainage system were protective factors against the need for transfusion.⁴¹

Antifibrinolytic drug use has been linked to decreased intraoperative blood loss and postoperative transfusion rates.⁴²

Preoperative autologous blood donation (PABD) patients are more likely to be able to donate blood before surgery while receiving erythropoietin therapy. This has the effect of reducing hemoglobin and hematocrit levels loss.⁴³ According to a study, TXA is a transoperative technique that can help patients having primary total hip arthroplasty avoid the requirement for allogeneic blood transfusions.⁴⁴

Evidence suggests that preoperative recombinant human erythropoietin (rHuEPO) and iron therapy for anemic adults before non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively.⁴⁵

In the era of restrictive transfusion thresholds, the maximum surgical blood order schedules (MSBOS) suggest that preoperative hemoglobin levels (<11 g/dL and <9 g/dL) should be taken into account when determining the number of units to type and crossmatch, respectively, prior to surgery.⁴⁶

Cell saver (CS) considerably reduces the need for allogeneic blood transfusions (ABT) during and after surgery.⁴⁷ The use of a tourniquet during total knee arthroplasty (TKA) may reduce intraoperative blood loss safely, but not postoperative blood loss or actual total blood loss.⁴⁸

A pneumatic tourniquet clear the surgical site from blood, minimizing blood loss and enhancing, in particular, knee replacement and cementing. However, blood stasis can cause neuromuscular dysfunction and thromboembolic consequences, with severity directly correlated with tourniquet time.²⁴ Combined intra-articular and intravenous TXA regimen significantly reduced perioperative blood loss compared with only intravenous (IV) TXA until 7 days after TKA.⁴⁹

Patients undergoing total knee arthroplasty should follow a protocol that includes regional anesthesia, the use of tourniquets and post-closure deflation, femoral canal plugging or femoral canal sparing surgical techniques, the use of TXA (topically or intravenously), and drain avoidance.⁵⁰ In total joint arthroplasty (TJA), intraoperative hypothermia is linked to higher rates of blood loss and transfusion. When operating on these individuals, efforts should be taken to maintain normothermia.⁵¹

An effective combination of erythropoietin application, iron therapy, intraoperative controlled hypotension for bleeding management, and tranexamic acid administration can produce positive clinical outcomes.⁵²

In Jehovah’s Witness (JW) patients undergoing total knee arthroplasty (TKA), a combination of hypotensive anesthesia, intravenous administration of TXA, intraoperative periarticular injection, and cell salvage appear to be sufficient in controlling the blood loss; however, further tourniquet use may not further reduce the anticipated blood loss.⁵³ The treatment of blood loss is significantly influenced by surgical technique, awareness of the issue, and restrictions on transfusion triggers.⁵⁴

Preoperative hemoglobin, anesthetic type, use of tranexamic acid, and age were found to be significant predictors of postoperative blood transfusion as per one study.⁵⁵

In complete hip and knee replacements, postoperative cell salvage is effective and safe in lowering the need for allogenic blood transfusion (ABT).²⁷

We recognise that this study has limitations; it depended on a small number of databases, may have biased the selection of articles, lacked data analysis, and used outdated references. It also did not involve systematic or meta-analysis.

Conclusion and Recommendations

Patients who are at danger of bleeding during surgery or who are anemic should be handled with medication, allogenic blood transfusions, adjuvants, and non-pharmacological methods such tourniquets and cell savers. Most essential, healthcare professionals should pay close attention to patient status during the perioperative phase and use a variety of transfusion procedures rather than relying just on one.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflicts of interest in this work.

Acknowledgment statement

We appreciate the University of Gondar’s assistance in facilitating our access to published articles via their institutional email account.

Additional information

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.