Blood Transfusions Shouldn’t Be Part of the Routine for TJA Patients
Decisions around blood management in total joint arthroplasty patients may not be supported by a great deal of literature, but it’s hard to call these practices “urban legends” – there is consensus among leading orthopaedic surgeons on many of them.
One thing is clear: Surgeons today are more conscientious about blood management than in the past, taking steps to avoid transfusions that would have been routine not long ago.
At ICJR’s Winter Hip & Knee Course, Ryan M. Nunley, MD, from Washington University, St. Louis, Missouri, addressed perioperative strategies to reduce transfusions as part of the series of lectures on urban legends in total joint arthroplasty.
Dr. Nunley noted that blood management plays a significant role in perioperative management, rapid recovery, outcomes, and patient satisfaction with total joint arthroplasty, and it is especially important in light of bundled payment models and quality of care initiatives. Orthopaedic surgeons may have been quicker to transfuse in the past, but now “every drop counts,” he said, and surgeons should do all they can to reduce transfusion rates.
Why does this matter so much? Blood transfusions are associated with increased morbidity and mortality, as well as staggering costs to the healthcare system. [1,2]
Patients who receive blood transfusions are at risk for transmission of infections from the donor, and may also experience: 
- Increased surgical site infection
- Cardiac and lung injuries
- Delayed recovery
- Longer hospital stays
- Increased mortality
Rates of blood incompatibility and transfusion reactions are not as insignificant as surgeons might think: Dr. Nunley said they are quite common, with as many as 75% of patients who receive a transfusion experiencing some type of mild reaction.
Dr. Nunley also quoted a study on the financial cost of blood transfusions. The 464 hospitals included in the data review had spent more than $75 million on transfusions for 358,617 surgeries, with each transfusion valued at $211.  But $211 is only the acquisition cost of the blood. Due to added nursing care, delayed physical therapy, and delayed discharge, the true cost of a transfusion at these hospitals was 3.8 to 4.2 times higher, which translated to more than $378 million. 
The solution to blood loss and transfusions, Dr. Nunley said, starts with appropriate preoperative planning and perioperative protocols. Be sure to identify patients preoperatively who have anemia or other risk factors for postoperative transfusion. The preoperative assessment should include:
- Nutritional status
- Body weight
- Cardiovascular status
- Exercise tolerance
Mildly anemic patients can receive supplementation with iron, folate, B12, vitamin C, and protein.
During the procedure, surgeons can minimize blood loss with:
- Spinal anesthesia and intraoperative hypotension
- Shorter surgical times
- Tourniquet use
- Use of cautery, bipolar sealants, or argon beam
- Cell saver use, particularly in high-risk patients such as Jehovah’s witnesses
- Use of antifibrinolytic agents such as tranexamic acid
So, who should receive a transfusion? Use the patient’s symptoms as a guide, Dr. Nunley said. He limits transfusions to symptomatic patients, such as those who have a hemoglobin lower than 6 and orthostatic symptoms on standing. Asymptomatic patients, even those with a hemoglobin between 6 and 8, do not get a transfusion.
Click the image above to watch the presentation by Dr. Nunley, who also discusses antibiotic prophylaxis and penicillin allergy.
Dr. Nunley has no disclosures relevant to this presentation.
- Anthes, E. Evidence-based medicine: Save blood, save lives. Nature. 2015;520:24.
- Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals, Transfusion. 2010;50:753-65.